Mental Health Form: A

a nurse is admitting a client who has alcohol use disorder. which of the following statements by the client indicates that the client is using denial as a defense mechanism?

"I am able to go to work everyday, so I don't have a problem."

a nurse in a clinic is assessing a client whose partner died 4 months ago. which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning."

pt has anxiety disorder. which statement by the pt. indicates successful use of guided imagery?

"I imagine myself lying on a quiet beach when I start to feel anxious."

new d/x of alzheimers disease and is to start taking donepezil. statement to be included in the teaching?

"Take this med in the evening at bedtime."

interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. the nurse should ask which of the following questions to determine the pt. ability to cope with this situation?

"To whom do you talk when you feel overwhelmed?"

a nurse in a community health center is counseling a family of 2 parents and 2 children. which of the following statements by a family member indicates manipulative behavior?

"if you do my homework for me, I wont bother you for the rest of the day."

a charge nurse is preparing an educational session for a group of newly licenced nurses to review client rights under the law. Which of the following statements should the nurse make?

"in the event a client threatens harm to others, meds can be administered without consent."

a nurse is planning care for a client who has depression and has made frequent suicide attempts. which of the following statements indicates the client has a decreased risk for suicide?

"it is easier to talk about my feelings now."

a nurse is caring for a client whose child has a terminal illness. the client requests info about how to deal with the upcoming loss. which of the following statements should the nurse make?

"it is not uncommon to feel angry toward yourself or to others."

A nurse is caring for a client who is undergoing ECT and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make?

"succinylcholine is a muscle-paralyzing agent that will decrease muscle movement during the procedure so the client is less likely to be injured."

a nurse is documenting admission assessment findings for a client who has major depressive disorder. the nurse should identify which of the following findings as clinical manifestations? (SATA)

-feelings of hopelessness -anhedonia -flat facial expression

math....0.55mg/kg PO, pt. weighs 110lbs. available is 10mg/5mL

14

a nurse is an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. the nurse should advice the client that which of the following supplements interacts adversely with paroxetine?

St. John's wort

a nurse is caring for a group of clients. for which of the following situations should the nurse complete an incident report?

a client was administered one-half of the perscribed dose of medication.

a nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity?

a client who has a NA level of 128mEq/L

a nurse is caring for a group of clients. which of the following findings is the nurse required to report?

a client who has borderline personality disorder threatened to harm their roommate.

a nurse is caring for a group of clients. which of the following findings should the nurse report? A client who is taking clozapine and had wbc count of 7500 A client who is taking lamictal and has develop rash A client who is taking valproate and has platelet count of 150000 A client who is taking lithium and has lithium level of 1.2

a client who is taking lamotrigine (an anticonvulsant) and has developed a rash

a nurse is providing teaching to a client who is to begin undergoing light therapy at home. which of the following info should the nurse include in this teaching?

avoid looking directly at the light during treatment

a nurse is assessing a school-age child who has conduct disorder. which of the following characteristics should the nurse expect the child to demonstrate?

agression towards animals

a client who has a d/x of depression is attending group therapy. during the group meeting the nurse asks each member to identify one goal for the day. when it is the client's turn, they do not respond. which of the following actions should the nurse take before repeating the request to the client?

allow the client time to formulate an answer

a nurse is assessing a client who has schizophrenia. which of the following findings should the nurse document as a negative symptom of this disorder?

anhedonia

a nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. which of the following interventions should the nurse identify as the priority?

arrange a one-on-one observation of the client

a nurse on a mental unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

ask the client what the voices are saying

a client with paranoid schizophrenia is attending a treatment planning conference with a family member. during the discussion of the medication adhernce portion of the plan, a nurse notices that the family member seems distracted. which of the following actions should the nurse take?

ask the family member if they have any thoughts or questions about the treatment plan

during morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. the client reports that a bomb was placed in their room by a family member during visiting hours. which of the following actions should the nurse take?

assess the client for evidence of a perceptual disturbance.

a nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. which of the following post-discharge activities should the nurse plan to include?

attending a relapse prevention group several times each week

a nurse is communicating with a client in an inpatient mental health facility. which of the following actions by the nurse demonstrates the use of active listening?

attention to body language

a nurse is delegating client care tasks to a licenced practical nurse (LPN) and assistive personnel. which of the following tasks should the nurse assign to the LPN?

change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

a nurse is admitting a client who has schizophrenia to an acute care setting. when the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the speech pattern as?

clang association

a home health nurse is assessing an older client whose sibling is the primary caregiver. which of the following should the nurse identify as a possible indicator of neglect?

inappropriate dress

a nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the med?

hand tremors

a nurse in a provider's office is collecting a health h/x from the guardian of a school-age child who has been taking atomoxetine. which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

dark urine

charge nurse observes an AP slapping an older adult pt. after moving the pt to safety, which is the priority action?

determine if the client has been physically harmed.

a nurse in an ED is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hour ago. The client has a h/x of depression and a BP of 210/105 and a temp of 103.8 (39.9) which of the following actions should the nurse take first?

determine the client's prescribed medication regimine

a nurse is caring for a client who is experiencing alcohol withdrawl. which of the following meds should they administer first?

diazepam 5mg IV bolus

a nurse is caring for a client who has a h/x of substance abuse disorder and was involuntary admitted to a mental health facility. when the nurse attempts to administer oral lorazepam, the client refuses to take the med and becomes physically aggressive. which of the following actions should the nurse take?

do not adminster med

a nurse is assessing a client who has boderline personality disorder. which of the following findings should the nurse expect?

emotional lability

a nurse is planning care for a client who is experiencing acute mania. which of the following interventions should the nurse include in the plan to promote sleep?

encourage frequent rest periods throughout the day.

a nursing is admitting a client who has anorexia nervosa and is at 6015 of the ideal body weight. which of the following interventions should the nurse include in the plan of care?

encourage the client to drink 125mL of fluid each hour while awake.

planning prevention strategies for intimate partner abuse in the community. which of the following strategies should the nurse include as a method of secondary prevention?

establish screening programs to identify at-risk clients

a nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. the client's partner asks the nurse about expected manifestations. the nurse should teach the partner to expect which of the following manifestations to occur first?

frequently misplaces objects

a nurse in the ED is caring for a client who has alcohol toxicity and is unresponsive. which of the following interventions should the nurse take?

gather supplies for endotracheal intubation

a nurse is obtaining a mental health h/x from an older adult client. which of the following actions should the nurse plan to take?

interview the client in a private setting

caringfor a pt. who has attempted suicide and has alcohol use disorder. statement that indicates that the pt. is using a positive coping mechanism.

"I will attend daily group therapy sessions to practice relaxation techniques."

caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. which of the following therapeutic nursing interventions is the priority?

use a therapeutic holding technique

teaching to a pt who is to begin undergoing light therapy at home to treat seasonal affective disorder. teaching should include what?

wear sunglasses when outdoors

a nurse in a mental health clinic is planning care for a client who has a new Rx for olanzapine. which of the following interventions should the nurse identify as the priority?

instruct the client to avoid driving during initial therapy.

a nurse is assessing a client who recently used cocaine. which of the following findings should the nurse expect? Polyphasia, hypertension, decreased temperature, depressed mood

hypertension

a nurse is planning discharge for a client who has bipolar disorder and has a Rx for lithium. which of the following client statements indicates understanding of the teaching about the med?

i should eat a regular diet with normal amounts of salt and fluids

a nurse is admitting a female client who has anorexia nervosa. which of the following manifestations should the nurse expect during the admission assessment?

orthostatic hypotension

a nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. which of the following interventions should the nurse include in the plan?

promote the use of music to compete with the clients auditory hallucinations

a nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. which of the following is the priority action by the nurse?

provide frequent high-calorie snacks

a nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. which of the following client behaviors indicates effectiveness of the therapy?

refrains from manipulating others to earn dining privleges

a nurse is planning care for a 7 year old child who has ADHD. which of the following interventions should the nurse identify as the priority?

remove unnecessary equipment from the child's surroundings.

a nurse is caring for a client in a mental health facility. the nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

report the occurrence to the charge nurse

a nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver?

respite care

a nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. which of the following strategies should the nurse use when communicating with this client?

set realistic limits on the clients behavior

a nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. which of the following findings indicates the nurse should administer benzotropine 2mg IM?

shuffling gait

action that is an example of the ethical principle of justice?

spending adequate time with a client who is verbally abusive

a community health nurse is planning an education program about depressive disorders. which of the following factors should the nurse include as increasing the risk for depression?

substance use disorder

a nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. which of the following actions should the nurse take?

talk with the client about activities they enjoyed with their partner.

criteria required for hospitalization of anorexia nervosa?

temperature 35.6 (96.1)

during a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

the client is interested in what the nurse is saying

while observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. which of the following behaviors is consistent with this condition?

the client needs excessive external input to make everyday decisions.

a nurse is caring for a client who is experiencing a situational crisis. which of the following findings should the nurse expect?

the client recently lost a grandparent in a MVA

a nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

the client reports an inability to breathe easily.

a nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

the client reports command hallucinations

reviewing the chart of a pt. who has dissociative amnesia. which findings should the nurse expect?

the client was seriously injured while under the influence of alcohol

a nurse is caring for a client who has borderline personality disorder. which of the following goals is the priority when planning care for this client?

the client will refrain from self-mutilation

a nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

total body fat 8.7%

a nurse is teaching a client who has a depressive disorder about fluoxetine. which of the following information should the nurse included in the teaching?

you might expierence difficulties with sexual functioning while taking this med