Mental Health Final

A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." What response should the nurse make? "What we say is not being recorded." "Let's ignore the voices and talk about something else." "That must be very frightening." "Why do you think the TV is a two-way radio?"

"That must be very frightening." The nurse should respond to the client's delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship.

A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for what substance? Amphetamines Opiates Barbiturates Hallucinogenics

Opiates. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestions of opiate withdrawal.

A nurse is evaluating the plan of care for a client who has antisocial personality disorder. What actions indicate that he is making progress with the treatment? Assisting another client who has depression to fill out a menu Nominating himself to chair the client government meeting Requesting a weekend pass to go home Serving as the judge for a unit talent show Informing the nurse that the staff provides excellent care to clients

-Assisting another client who has depression to fill out menu -Requesting a weekend pass to go home

A nurse in an acute mental health facility is leading a nursing staff discussion about the legal aspects of involuntary admissions. What information should the nurse include? A client who is involuntarily admitted must take prescribed medications. An involuntary admission of a client is limited to 2 weeks. A client who is involuntarily admitted can leave the facility against medical advice. An involuntary admission is justified if the client is a danger to others.

An involuntary admission is justified if the client is a danger to others; --> a client who is a danger to other or to himself qualifies for an involuntary admission. The inability to meet basic needs due to the need for mental health treatment is also a justification for an involuntary admission

A nurse is caring for a client who is receiving treatment for alcohol detoxification. What medication should the nurse expect to administer during this phase of the client's care? Buprenorphine Diazepam Varenicline Rimonabant

Diazepam. Anti-anxiety agents, such chlordiazepoxide and diazepam, are long-acting CNS depressants that are used to minimize the manifestations of alcohol withdrawal

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What action should the nurse take? Monitor the client's liver function while taking this medication. Increase the dosage of this medication every 72 hr. Offer the client a PRN NSAID while taking this medication. Administer the medication at bedtime.

Administer the medication at bedtime.

A nurse is assessing a client who has conduct disorder. What finding should the nurse expect? Fearfulness of authority figures Flat affect Preoccupation with enforcing rules Aggressive behavior toward others

Aggressive behaviors towards others The nurse should expect the client who has conduct disorder to exhibit aggression toward others and impulsively violate others' rights.

A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. What behaviors should the nurse expect the client to display? Relief about finally receiving care for a problem for which he was previously afraid to ask for help Anger with the nursing staff for hospitalizing him against his will Withdrawal from others due to shame over his recent actions Remorse for stealing and des

Anger with the nursing staff for hospitalizing him against his will A client who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation goes against his will or desires.

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall very rapidly and muttering in an angry way. What action should the nurse take first? Apply mechanical restraints to the client. Administer PRN haloperidol IM to the client. Approach the client in a nonthreatening manner. Place the client in seclusion.

Approach the client in a nonthreatening manner; --> the first action the nurse should take is to approach the client calmly, in a nonthreatening manner, to create a nonthreatening environment. the nurse should apply the least restrictive priority-setting framework when caring for this client. this framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. the nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk.

A nurse is caring for a client who has depression. The client states "i am too tired and depressed to attend group therapy today". What response should the nurse make? "Attending group therapy, even if you're tired, is an important part of your treatment." "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." "I agree with your decision to wait

Attending group therapy, even when your tired, is an important part of your treatment; --> then nurse provides a therapeutic response by giving the client information to make an informed decision. group therapy is beneficial to the client who has depression by promoting peer support and reducing social isolation

A nurse is obtaining a client's medical history prior to scheduling the client for electroconvulsive therapy (ECT). What should the nurse identify as a potential complication? Severe depression Cardiac arrhythmia Bipolar disorder Parkinson's disease

Cardiac arrhythmia; --> a client who as a cardiac arrhythmias needs further evaluation. the nurse should identify that the greatest risk for death due to ECT is related to cardiac complications

A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect? Increased arousal Arrhythmias Confusion Esophageal pain

Confusion. The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are expected findings of this disorder.

A nurse is performing an admission assessment for a client who has restricting type anorexia nervosa. What finding should the nurse expect? Recurrent binging Compensatory vomiting Loss of appetite Decreased caloric intake

Decreased caloric intake. The nurse should expect the client who has restricting type anorexia nervosa to have a restricted and decreased caloric intake due to the client's intense fear of weight gain

A nurse is caring for a client who just received a terminal diagnosis of cancer. What initial reaction should the nurse expect? Bargaining Depression Denial Anger

Denial. The nurse should expect the client to initially deny the reality of the diagnosis. This is a protective reaction that serves to protect the client from psychological pain.

A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which manifestations is a common adverse effect of this medication? Confusion Bradycardia Dizziness Insomnia

Dizziness. The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined.

A nurse is providing teaching to the family of a client who has Alzheimer's disease about donepezil. What statement should the nurse include in her teaching? Donepezil can improve cognitive functioning during the earlier stages of the disease." "Donepezil cures the disease process if it is started upon first recognition of dementia." "Donepezil provides long-term reversal of memory loss in the last phase of the disease." "Donepezil accelerates the breakdown of acetylcholine within the client's

Donepezil can improve cognitive functioning during the earlier stages of the disease The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe Alzheimer's disease. Although donepezil does not prevent the progression of Alzheimer's disease, it is intended to prolong the client's ability to function in the early stages of the disease.

A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the priority for the nurse to report to the provider? Elevated blood pressure Weight gain Muscle twitching 2+ peripheral edema

Elevated blood pressure. The nurse should identify that the greatest risk to the client is an elevated blood pressure, which increases the risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction priority-setting framework when assessing this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting frame-work, or nursing knowledge to identify which risk poses the greatest risk.

A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. What finding should the nurse question the provider's prescription? A skeletal muscle injury History of status epilepticus Hypotension Insomnia

Hypotension. The nurse should question the provider's prescription for a benzodiazepine for a client who has hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac arrest.

A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity disorder (ADHD).What should the nurse include in her teaching? Ignore your child's attention-seeking behaviors that are not dangerous." "Administer ADHD medications within 30 minutes of your child's bedtime." "Continue with an activity as planned even if your child becomes frustrated." "Expect your child to gain weight after starting ADHD medications."

Ignore your child's attention-seeking behaviors that are not dangerous

A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. The client tells the nurse he has not had anything to drink for 6 hours. What should the nurse expcet? Low body temperature Insomnia Muscle flaccidity Bradycardia

Insomnia; --> the nurse should expect the client who is experiencing alcohol withdrawal to have insomnia and restlessness

A nurse in an acute mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD). What action should the nurse include in the plan? Encourage the client to focus on personal hygiene. Limit the hours the client sleeps each day. Instruct the client to practice thought stopping. Make negative statements about the client's behavior.

Instruct the client to practice thought stopping. The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out loud, the client can learn to interrupt obsessive thoughts.

A nurse is developing a plan of care for a client who has anorexia nervosa. What action is contraindicated for this client? Explaining that tube feedings are necessary if the client refuses oral intake Weighing the client each day prior to any oral intake Permitting the client to spend some quiet time alone after each meal Refraining from commenting about the client's eating during meal times

Permitting the client to spend some quiet time alone after each meal; --> the nurse should directly observe the client for a minimum of 1hr following meals. the intervention prevents the client from purging or discarding hidden food. therefore, permitting the client to have alone time following meals is contraindicated for his plan of care

A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he isn't going to attend any further sessions and states "I don't have time for all that talking. What response should the nurse provide? "It must be difficult for you to talk about family problems." "You should continue attending the family counseling sessions until the therapist tells you to stop." "If you continue to go to family counseling, I'm sure you'll be abl

It must be difficult for you to talk about family problems. The nurse's response indicates empathy for the client's feelings and is an example of the therapeutic communication technique of verbalizing what the client implied. With this technique, the nurse helps him focus on the actual reason for not wanting to continue family therapy.

A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should the nurse plan to take? Restrict participation in group therapy sessions. Establish consequences for self-mutilation. Maintain close observation of the client. Provide an unstructured environment.

Maintain close observation of the client. Clients who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. What client goals should the nurse identify as a priority? Practicing problem-solving skills Understanding of medication regimen Identifying indications of relapse Maintaining adequate hydration

Maintaining adequate hydration.

A nurse is planning a staff education session about the administration of antidepressant medications to older adult clients. What should the nurse include in the teaching? Older adult clients require a lower initial dose of antidepressant medication than adult clients. Older adult clients should not receive antidepressant medication. Older adult clients achieve the therapeutic effects of antidepressant medications more quickly than adult clients. Older adult clients have a decreased risk for ad

Older adult clients require a lower initial dose of antidepressant medication than adult clients

A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. The nurse should identify what interventions as the priority when planning care for this client? Promoting and maintaining client safety Discussing reasons for the client's behavior Assisting the client to recognize feelings Teaching the client alternative coping strategies

Promoting and maintaining client safety; --> the nurse should recognize that the client who has self-inflicted injuries is at risk for further self-harm or suicide; therefore, the pt's safety is the priority. the nurse should apply the safety and risk reduction priority-setting framework when planning care for this client. this framework assigns priority to the factor or situation posing the greatest safety threat is the highest priority. the nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. What is the nurses priority? Maintain the client's contact with her family. Discourage the client's use of vulgar language. Protect the client from impulsive behavior. Redirect excessive energy to creative tasks.

Protect the client from impulsive behavior.

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. What intervention should the nurse include in the plan? Discourage the client from taking naps during the day. Allow the client to choose which clothing to wear each day. Encourage the client to participate in group therapy. Provide the client frequently with high-calorie finger-foods.

Provide the client frequently with high-calorie finger foods. The nurse should provide the client with frequent, high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client's intake by making it easier to eat when mania makes it difficult for her to sit down and concentrate on a meal.

A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. What dietary choices should the nurse instruct the client to avoid? Peppermint candy Pure vanilla extract Salt Chocolate

Pure vanilla extract. The nurse should instruct the client to avoid alcohol and alcohol-containing substances such as pure vanilla extract. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension.

A nurse is assessing a client who experienced a sexual assault six months ago. What should the nurse report to the provider? Flat affect Refusal to accept help from others Report of intense guilt Denial of the sexual assault

Report of intense guilt; --> the nurse should expect the client who has rape-trauma syndrome to experience guilt about the sexual assault. these feelings of guilt can delay the healing process and produce a sustained and maladaptive response

A nurse in the emergency department is assessing a client who has heroin intoxication. What should the nurse expect? Seizure activity Respiratory depression Hypersensitivity to pain Increased mental alertness

Respiratory depression Heroin is an opioid; therefore, the nurse should expect the client who has heroin intoxication to exhibit respiratory depression.

A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The nurse should expect a prescription for memantine for a client who has what diagnosis? Postpartum depression Schizophrenia Obesity Severe Alzheimer's disease

Severe Alzheimer's disease. the nurse should expect a prescription for Memantine for a client who has moderate to severe Alzheimer's disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and to improve cognitive function

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. What techniques should the nurse use to facilitate communication with the client? Continue to talk if the client does not provide an immediate verbal response. Use platitudes when talking with the client. Ask the client direct questions. Speak to the client using simple and concrete terminology.

Speak to the client using simple and concrete terminology The nurse should use simple and concrete terminology when communicating with this client. The client who is severely withdrawn has impaired comprehension and difficulty concentrating; therefore, this technique facilitates communication.

A nurse is interviewing a client who has anorexia nervosa. What findings should the nurse expect? Poor personal hygiene habits Strenuous exercise regimen Grandiose behaviors Intense fear of death

Strenuous excercise regimn The nurse should expect the client who has anorexia nervosa to report a strenuous exercise regimen. The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight.

A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that a member of the group requires further teaching when she identifies what manifestation of the disease? Impaired judgment Sudden confusion Personality change Remote memory loss

Sudden confusion The nurse should clarify that the client who has Alzheimer's disease is expected to exhibit confusion that develops slowly over a period of months. Clients who have delirium exhibit sudden confusion.

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygience care. What action should the nurse take? Talk to the client from two arm-lengths away. Obtain assistance to restrain the client for safety. Firmly state to the client that morning care will be performed. Call the provider to request a prescription for an antipsychotic medication.c

Talk to the client from two arm-lengths away. The nurse should talk calmly and quietly to the client to decrease her agitation. The nurse should remain one to two arm-lengths away to provide her with a sense of personal space and maintain safety if she becomes aggressive.

A nurse is planning care for a client who has a physical dependence to alprazolam and must discontinue the medication. WHAt action should the nurse include in the plan? Taper the medication gradually over several weeks. Encourage participation in stimulating physical activity. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication. Implement restraints and seclusion as needed.

Taper the medication gradually over several weeks; --> the nurse should plan to taper the dosage of alprazolam gradually over several weeks, possibly months. The gradual reduction in dosages reduces the manifestations of withdrawal

A nurse is assessing a client who has Stage 4 Alzheimer's disease. What finding should she expect? The client requires assistance with eating. The client independently manages personal finances. The client has bladder incontinence. The client is able to identify the names of family members.

The client is able to identify the names of family members. The nurse should expect the client who has Stage 4 Alzheimer's disease to recognize and identify family members. Clients who have Alzheimer's disease maintain this ability until Stage 6.

A nurse in the emergency department is caring for a toddler who has a fractured arm. What findings should the nurse identify as a possible indication of physical abuse? The parent provides a history that is inconsistent with the child's injury. The child is brought to the emergency department immediately following the injury. The parent requests to remain present with the child throughout treatment of the injury. The child clings to the parent when the nurse begins to assess the injury.

The parent provides history that is inconsistent with the child's injury The nurse should suspect possible abuse when the child's injury conflicts with the history of the injury that is reported by his parent.c

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription of lithium. The nurse should identify that it is safe to administer what medication while the client takes lithium? Ibuprofen Haloperidol Valproic acid Hydrochlorothiazide

Valproic acid. Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for the nurse to administer both of these medications to the client.

A nurse is providing teaching to a client who is to start taking valproic acid. What should be included in the instructions? "You should expect the provider to gradually decrease your dosage of valproic acid." "You should take aspirin for pain you have while taking valproic acid." "You should undergo thyroid function tests every 6 months while taking valproic acid." "You should have your liver function levels monitored regularly while taking valproic acid"

You should have your liver function levels monitored regularly while taking valproic acid; --> the nurse should inform the client of the need to regularly monitor liver function levels due to the risk of hepatotoxicity while taking valproic acid. it is recommended to obtain baseline levels and then repeat every 2 months during the first 6 months of therapy

A nurse is teaching a client who has agoraphobia about systematic desensitization. What comment should the nurse include in the teachings? "You will watch from a secure location as your therapist goes to public spaces." "You will start your therapy by staying in a public space until your anxiety decreases." "You will be instructed to say 'Stop!' out loud when you become anxious in public spaces." "You will slowly be exposed to increasing levels of public spaces."

You will slowly be exposed to increasing level of public spaces The nurse should inform the client that, using systematic desensitization, she will be gradually exposed to the feared situation under controlled conditions until she learns to overcome the anxious response.

a nurse is assessing a client who has binge-eating disorder. which of the following findings should the nurse expect? amenorrhea abdominal pain Restricted caloric intake frequent use of laxatives

abdominal pain the nurse should expect the client who has binge-eating disorder to report problems with abd pain. this is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food

A nurse in an emergency room is assessing a client who has cocaine intoxication. What finding should the nurse expect? Low blood pressure Dilated pupils Conjunctival redness Decreased body temperature

dilated pupils. Dilated pupils are associated with the use of cocaine.

A nurse is caring for a client who has alcohol use disorder. FOllowing alcohol withdrawal, what medication should the nurse expect to give the client during maintenance? Methadone Disulfiram Chlordiazepoxide Naloxone

disulfiram; --> the nurse should expect to administer disulfiram as deterrent to prevent future use of alcohol. the nurse must ensure that the client has not had any alcohol intake for at least 12hr prior to administration

A nurse is interviewing an older adult client about possible abuse by her caregiver. What technique should the nurse use? Avoid directly asking the client if she has been abused. Use a confrontational approach. Maintain a nonjudgmental tone. Avoid being in the room alone with the client.

maintain a nonjudgmental tone which promotes trust and communicaton.

A nurse in an acute substance disorder unit is assessing a client who received treatment in the emergency department for a heroin overdose. What finding should the nurse anticipate during heroin withdrawal? Excessive sleeping Muscle aches Pupillary constriction Absent bowel sounds

muscle aches. The nurse should expect this and other manifestations of withdrawal to begin within 6 to 8 hours following the last dose of heroin

A nurse on an acute care unit is providing postoperative care to an older client who develops delirium. What action should the nurse take? Request a prescription for an antianxiety medication. Provide the client with a stimulating activity prior to bedtime. Keep the lights in the client's room dim at night. Encourage the client to make decisions about her daily routine.

request a prescription for an antianxiety medication; --> the nurse should request a prescription for an antianxiety medication for a client who develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety and agitation

A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. What adverse effect should the client expect? Tinnitus Bradycardia Halitosis Sedation

sedation. ; the nurse should tell the client to expect sedation as an adverse effect of benzodiazepines because of the CNS depression effects