Mental Health HESI (? Only)

teenaged girl self-induced vomiting

frequency of binging and purging behaviors

Woman is at a meeting with you, what is important for the nurse to document after hearing her issues in the relationship

get spouses statement as well

Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview?

B. Describe self as a social drinker who drinks alcoholic beverages daily.

The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?

B. Remain alcohol free for 12 hours prior to the first dose.

A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?

A. Offer to play a game of cards with the client.

The nurse is teaching a pt about disulfiram (Antabuse)

-Refrain from alcohol 12 hrs prior to first dose

A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nures take?

-plan a list of activities to be carried out daily

adolescent teen interrupts group about pets at home

-redirect him to read from materials

depression remains in bed most of the day, declines activities and refuses meals

-refusal to address nutritional needs

10. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding

-remain alcohol free for 12 hours prior to the first dose

depressed mother and daughter speaks in group

i hear you say you worry about your mother's distress

Psychomotor retardation, hypersomnia, and amotivation; what nursing intervention?

-teach client to have daily structured activities

24. client who refuses antipsychotic medication disrupt group activities nurse decides client needs constant observation based on?

-wanders into client's room

The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment?

. Do you frequently have temper tantrums?

An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?

D) Accompany her outside for an increasing amount of time each day.

How do you take Antabuse

Each morning beginning 48 hours after your last drink of alcohol

A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client's verbal and nonverbal communication. What action does the RN take?

A. Pay close attention and document the nonverbal messages.

Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do?

Leave and come back 30 minutes later.

A chronic depressed older man refuses to leave his room. His family moved away to a further location so they're not able to visit him as much. What approach should the nurse take with this man?

May I lay with you for a little?

A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

A. Place in a side-lying position with head of bed elevated.

The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP?

A. Potassium level of 2.9 mEq/dl.

Chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room

May I sit with for you a while

After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. What action should the nurse take?

A. Recommend assignment to the receptionist's office.

In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response?

Redirect the client to read the handout.

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement?

A. Report the client's serum lithium level to the HCP.

A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take?

A. Stay quietly with the patient

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client's rooms. The RN decides that the client needs constant observation based on which of these assessment findings?

A. Wanders into the clients rooms.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

A. Is attempting the physically restrain the patient.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN?

A. Is attempting to physically restrain the patient.

A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

A. Not sleeping for several days.

A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take?

A. Offer the client a safe place to relax before interviewing her.

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

A. Weight gain of 75 lbs.

21.ECT pre treatment teaching

-NPO after midnight

When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide?

"Have the feelings associated with these events brought you to the clinic?"

A 38-yea- old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make?

"I'll leave your tray here. I am available if you need anything else."

. Angry pt because of coworkers, then a car accident, what is the nurse best response?

-"several things made you angry?"

The nurse is preparing medications for a client with disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

-Benztropine (Cogentin)

A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations

-Risk for other related violence related to disruptive behavior

client sitting in corner of day room during admission assessment, what nursing action

-ask client simple questions

Client overdose on acetaminophen (Tylenol). What should the nurse monitor next?

-check for more narcotic effects

patient taking sertraline (zoloft) for postpartum depression, nursing teaching

-contact healthcare provider if having suicidal thoughts (black box warning)

11. A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care -delay business decisions until his mania subsides

-delay business decisions until his mania subsides

20.postpartum depression Sign & Symptoms (3)

-distrubed sleep, sadness, poor concentration

14. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

-do not take any over the counter meds

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

-establish trust by providing a calm, safe environment

teenaged girl self induced vomiting

-frequency of binging and purging behaviors

depressed pt in bed all weekend, nuse finds pt still in bed on her shift, what is the best action to take?

-get client out of bed and active

ECT therapy is not working, pt is non responsive to treatment what question should the nurse ask?

-have you taken erectile dysfunction meds

15. The nurse documents the mental status of a female client who has been hospitalized for several days by court order, The client states, "I don't need to be here" and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam?

-insight and judgement

13. Pt is getting oreiented to the unit and replies "there are no TVs in the room" What is the nurse's best respond?

-it is important to be out of your room and talking to others

Client makes a statement I feel like im going to die, what level of Anxiety is it?

-moderate anxiety

What documentation to include for abuse pts

-photographs

A client tells the nurse that his father died after the client thought abut it for a few days. The nurse suspects the client is delusional and is demonstrating:

A magical thinking

A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement?

A) Encourage the client to actively participate in assigned activities on the unit.

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse "I want to find out why these people are stalking me" which response should the nurse provide?

A. "It sounds like this experience is frightening for you"

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?

A. Acute confusion.

A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated?

A. Allow the client to rest and sleep.

Which nursing actions are likely to help promote the self-esteem of a male client with modern depression?

A. Ask the client what his long term goals are. D. Encourage the client to engage in recreational therapy. E. Provide opportunities for the client to discuss his concerns.

The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother?

A. Ask the mother if she has ever thought about harming herself or her child.

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?

A. Assist the client in developing alternative coping skills.

A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?

A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.

A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

A. Do not take any over the counter meds.

A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?

A. Ineffective sexual patterns.

A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care?

A. Initiate caloric and nutritional therapy.

A young adult male is hospitalized due to depression and an attempted suicide attempt. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving?

A. Initiates interactions with other clients.

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states"I don't need to be here," and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?

A. Insight and judgement.

A client comes into the ED with DTs. What should the nurse do first?

Administer Ativan.

A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response?

Advise the client that nursing assignments are not based on client requests.

Which patient would require CAGE assessment?

Alcohol patient, cut down, annoyed, guilty, eye opener

When opening a mental health clinic...

American Nursing Association.

A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take

Ask client about alcohol quantity, frequency, and time of last drink

Client sitting in corner of day room during admission assessment, what nursing action

Ask client simple questions

A depressed adolescent becomes sarcastic and irritates when you start to ask him questions. What does the nurse do?

Ask him to play cards

A nurse observes a client in the dayroom talking to himself. What should the nurse do first?

Ask the client if he's currently hearing voices?

When performing a MSE on a client which assessment intervention would best assist the nurse?

Ask the client to interpret the proverb a stitch in time saves nine.

After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first?

Assist the client out of bed and involve in activity.

what should you recommend to a patient saying she can't get any sleep recently after receiving news she has breast cancer. What medication should you recommend?

Ativan

A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention?

Attempt to distract the client with general conversation.

While setting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques?

B. Allow the client to identify the way he interacts.

A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

B) Are you ever alone when you hear the voices?

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment?

B) Moderate levels of anxiety.

On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

B) Participate in a group quilting project.

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will

B) control impulsive actions toward self and others.

A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide/

B. "My name tag shows that I am a RN here."

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client's current feelings of depression?

B. A sense of loss

Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is belligerent when another RN is assigned. What action should the charge RN implement?

B. Advise the client that assignments are not based on the client's request.

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. Which medication should also be discontinued?

B. Benztropine (Cogentin)

A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan?

B. Establish a code with family and friends to signify violence. C. Plan an escape route to use if the abuser blocks the main exit. D. Have a big ready that has extra clothes for self and children.

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)

B. Establish a code with family and friends to signify violence. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

B. Establish trust by providing a calm, safe environment.

A high school girl reveals to the high school RN that she has been engaging in self induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent?

B. Frequency of bingeing and purging behaviors.

A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client?

B. Have you taken any medications for erectile dysfunction?

A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority?

B. Help the client feel safe to decrease anxiety.

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

B. I am here because the police thought I was doing something wrong

A teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the RN to include in the clients plan of care?

B. Initiate caloric and nutritional therapy.

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here" and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam/

B. Insight and judgement.

The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT?

B. Keep the client NPO after mid-night.

A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN, "I feel like I'm going to die". Which nursing problem should the RN include in this client's plan of care?

B. Moderate anxiety.

A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?

B. Monitor vital signs.

A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take?

B. Offer to play a game of cards with the client.

A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?

B. Peperoni pizza.

The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?

B. Perform the dressing change in a non-judgmental manner.

The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation?

B. Photographs.

The nurse is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare providers

B. Potassium level of 2.9 mEq/dl

A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client?

B. Presence of a dry mouth.

A male client approaches the RN with an angry expression on his face and raises his voice, saying "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The RN recognizes that the client is using which defense mechanism?

B. Projection.

A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take?

B. Provide the client with medication if the client presents an imminent risk to self and others.

After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. What action should the RN take?

B. Recommend assignment to the receptionist's office.

A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

B. Remain alcohol free for 12 hours prior to first dose.

A female client on a psychiatric unit is sweating profusely while she vigorously does push ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?

B. Risk for other related violence related to disruptive behavior.

An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?

B. Sleep at least 6 hours a night.

A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client's plan of care?

B. Sleep deprivation.

A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

B. Teach the client to develop a plan for daily structured activities.

When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take?

B. Withhold the medication until the dosage can be confirmed.

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued

Benztropine (Cogentin)

The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?

C) Ask the client if he takes St. John's Wort routinely.

A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

C) low self-esteem.

recurrent negative symptoms of chronic schizophrenia and medication risperdal. walks laterally contracted position, something has made his body contort

administer the prescribed anticholinergic benztropine (cogentin) for dystonia

A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is

C) projecting her feelings onto the nurse.

The nurse orients a female client with depression to the new room on the mental health unit. The client states "It seems strange that I don't have a T.V in my room." Which statement would be best for the RN to provide?

C. "It's important to be out of you room and talking to others."

While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique?

C. Allow the client to identify the way he interacts.

The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

C. Assign the UAP to remain with the client at all times.

The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement?

C. Assist the client to get out of bed and involved in an activity.

An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?

C. Escort the client out of the bathroom.

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

C. Ineffective breathing pattern.

Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?

C. Infection control.

A male client with a long history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer?

C. Lorazapam (Ativan)

The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

C. Methamphetamine

Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

C. Observe the client for further narcotic effects.

A client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the RN identify as the priority?

C. Place in a side lying position with head of bed elevated.

A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

C. Plan a list of activities to be carried out daily.

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

C. Reduce the noise level in the room by turning off the television and radio.

A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client?

C. Refusal to address nutritional needs.

The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

C. Regularly scheduled unit activities for peer interaction.

A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client's family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority?

C. Remove all shaving equipment.

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first?

C. Take other clients in the area to the client lounge.

A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee's history is most related to the reaction that occurred?

C. Was physically abused by his mother.

onWhat should you advise a patient a MAOI not to eat?

Cheese, beer, and avocado.

Patient who is really depressed and won't talk or communicate, later is energetic and talkative. What should the nurse do?

Closely monitor the patient (could be suicidal)

A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism?

Compulsion.

A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother?

Consequences of enabling behaviors.

A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do?

Contact the person the client chooses to go to the home and remove the weapon.

Conversion disorder patient complains of blindness

Conversion disorder Disorder characterized by transferring a mental conflict into a physical symptom for which there is no organic cause. Ex: blindness, paralysis, seizures, deafness, and pseudocyesis(false pregnancy).

A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?

D) A negative view of self and the future.

The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make?

D) I'll be back in 30 minutes to help you get out of bed and walk around the room.

The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?

D) The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement?

D. "I don't want to walk. Nothing matters anymore."

During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers. How should the RN respond?

D. "It sounds as if there are many situations that make you feel angry."

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the RN take?

D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

The Rn is planning client teaching for a 35-year-old client with alcoholic cirrhosis. Which self-care measure should the RN emphasize for the client's recovery?

D. Alcohol abstinence.

When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide?

D. All clients are screened for domestic abuse because it is common in our society.

A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client's behavior?

D. Anxiety related to real or perceived threat to physical integrity.

A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?

D. Besides your sister's comments, what in your life is troubling you?

The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis?

D. Call for transportation to the hospital.

A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job she feels her employment is essential to the family's survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care?

D. Changes thought patterns related to problem solving.

On admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. Based on this statement, which intervention should the RN include in this client's plan of care?

D. Confront his delusion as not consistent with reality.

A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate?

D. Delusions of persecution.

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

D. Determine if Xanax was taken recently.

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client?

D. Do you hear sounds or voices that others do not hear?

A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?

D. Encourage the client to express her feelings regarding the upcoming procedure.

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. That intervention is best for the nurse to implement?

D. Escort the client to his room.

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?

D. Escort the client to his room.

The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?

D. Helping clients identify areas of problem in their lives.

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. What action should the nurse implement first?

D. Listen to what the client is saying.

Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?

D. Lorazepam (Ativan) 2 mg IM.

Following involvement in a motor vehicles collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures, The client's bold alcohol level is high on admission. Which PRN prescription should be administered if the client begin to exhibits signs and symptoms of delirium tremors (DT)?

D. Lorazepam (Ativan) 2mg IM.

A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer?

D. Lorazepam (Ativan).

While caring for an older client, the RN observes multiple bruises in Over the client's legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take?

D. Measure and document size, shape and color of the bruised areas.

The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment is most important for the RN to obtain?

D. Mental status examination.

The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

D. Nausea and vomiting.

A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

D. Offer the client a safe place to relax before interviewing her.

A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?

D. Provide the client with food in unopened containers.

The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take?

D. Redirect him by encouraging him to read from the handout.

The nurse leading a group session of adolescent clients give the members handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take?

D. Redirect him by encouraging him to read from the handout.

A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning?

D. Teach the client to develop a plan for daily structured activities.

A client with an anxiety disorder is demonstrating signs of panic. Which intervention would be the most appropriate for the nurse to implement

Decrease environmental stimuli and interactions with other people.

What are the side effects of Lithium?

Dehydration, diarrhea, and thirstiness.

A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia?

Delirium: Started in hospital.

The nurse overhears a client diagnosed with terminal cancer tell a family member that he will be discharged soon, will return to work, and plans to attend a company event scheduled in a year. The nurse realizes this client is demonstrating the defense mechanism of

Denial

A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx?

Disturbed thought process.

A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first?

Do you have a plan in place when you are not safe? (SAFETY!!!)

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client

Do you hear voices.

Antisocial- interrupting A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement?

Escort the client to a quieter place.

Who is most prone to being abused (elder abuse)?

Females over 75 living with their families.

What are the side effects of Resperdal?

Fever, tachycardia, and sweating.

Woman is diagnosed with breast cancer and she becomes dependent and asks family members if they can do ADL's that she is fully capable of doing. What is the reason for this behavior?

Its expected; regression is a natural start for recovery

A client taking Meth and Benzo's, what would the nurse prepare to do for overdose?

Give Narcan.

A client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first?

Go and get more staff assistance.

A client tells the nurse that he is an accomplished writer and that directors of television shows contact him for suggestions on actors and locations. The nurse realizes this client is experiencing the delusion of

Grandiosity

What would be proper teaching for a client who is to start taking Antabuse?

Has not had anything alcoholic to drink for the last 48 hours.

Mother has a 9 month old baby with mental issues and growth issues. The mother comes in and says she's depressed because she'll never have a normal baby. What should the nurse say?

Have you had any thoughts of harming your baby or yourself?

The nurse has identified the diagnosis imbalance Nutrition: More than body requirements for a client diagnosed with bulimia. Which intervention would be appropriate for this diagnosis?

Help client assess situations that precedes binging

A client is told to come in by friends, clients complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask?

What is troubling you the most?

A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)?

How would you like to be involved with your husband's care?

A female client diagnosed with depression tells the nurse that her husband wants her to "fix herself up" and put on nice clothes. The client continues by saying that she believes her husband is interested in another woman. What should the nurse respond to the client?

I can help you shower and get dressed before he comes to visit

A man who was stranded on the roof of his house for two days after a natural disaster, months later ...

Implement anxiety control strategies

Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome?

Importance of not quickly stopping the drug

During an assessment, a client from the Hispanic culture refuses to maintain eye contact with the nurse. After the nurse overhears the client say "evil eye" to a family member, the nurse realizes the client is demonstrating characteristics of which cultural-specific syndrome?

Induced by witchcraft

A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx?

Ineffective coping.

A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.

Infection control.

A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do?

Inform the sister.

A client tells the nurse that he has a fear of flying on an airplane but needs to attend a work-related meeting in another part of the country and will have to fly to get there. What can the nurse do to assist this client?

Instruct the client to visualize flying to the meeting destination

A business man is stressed about his finances, has anxiety and sleeplessness.

Limit intake of sugar and caffeine

A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test

Lithium is excreted by the kidneys and creatinine is related to kidney functioning

A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?

Lorazepam (Ativan) 8 mg PO HS

What is a common side effect of cocaine use.

MI

A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first?

Magnesium.

A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust?

Make brief contact with the client throughout the day.

Something about a male client threatening a teacher or becomes upset with teacher

Methods of clearly communicating (If you see this answer.. pick it!)

2 days after admission from alcohol withdrawal what should the nurse do?

Monitor HR and BP

A patient has stopped taking Depakote six months ago, what would the nurse assess?

Mood.

Patient watching TV starts talking loud to himself. The nurse comes in and can't distract him so turns down the TV. What should the nurse do then?

Move client to quieter room

A client comes to the nurses' station and told the nurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next?

Move the client to a private room by the nurse's station.

Patient having to get treated for benzodiazepam and methadone overdose. What do you use?

Narcan

What is the most important intervention for a client with bulimia?

Plan scheduled meals.

PTSD admitted to psychiatric unit, which intervention is most important for plan of care

Provide a quiet rook, away from the recreational area

A client diagnosed with schizophrenia has been refusing prescribed oral medication for several days. The client has broken chair and is coming after another client with the broken chair leg, threatening to do physical harm. What should the nurse do first?

Remove the other client from the room.

A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used?

Repression.

An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx?

Risk for injury.

Older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction?

What is your biggest concern?

A female client on a psychiatric unit is sweating profusely while she vigorously does push ups and then runs the length of the corridor several times before crashing into the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations

Risk for other related violence related to disruptive

A client comes in and is 5'5, 75lbs.. what should the nurse do

Start an IV for IV resuscitation

A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used?

Sublimation.

When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide

all clients are screened for domestic abuse because it is common in our society

An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do?

Take the woman aside and ask her about abuse.

A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do?

Take to quiet room and give PB crackers.

A client on LSD comes into the ER. How do you approach the client?

Talk calmly and soothing to the client.

In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the nurse do?

Talk in a calm, approaching manner

patient states "I can't get my thoughts together I should really sell my car. It's not in here. Let's buy a car. What is the patient experiencing?

Tangential thinking

An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

The emotional quality of his attitude

What would be the nurse's highest priority for a newly admitted depressed client upon admission?

The nurse should go through the client's belongings.

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

The nurse' ability to directly observe the client's nonverbal communication is limited with note taking.

A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a day." What can the nurse determine from this statement?

The parent is exhibiting tolerance to alcohol

A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery?

Thiamine will replenish alcohol effects on the body (something to do with iron)

A client with dementia uses the defense mechanism of confabulation. What is the reasoning?

To decrease anxiety.

History of alcoholism admitted for detoxification; 6mg of Ativan what additional prescription administer immediately

Vitamin B1(thiamine)

woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do?

Walk her to room and help her pick out something more appropriate

A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority?

Wandering in and out of other client's rooms.

The parents of a teenager who has overdosed what is the first question to ask?

What drug did the client ingest?

A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response?

When you interrupt, I cannot explain what to do to the group.

A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response?

You didn't do anything wrong. You have a chemical imbalance in your brain.

A client with Alzheimer's keeps asking for his mother. What is the nurses appropriate response?

Your mothers not here but you are safe.

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression

a sense of loss

A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition?

a. Dissociative disorder.

Patient says "I'm going to shoot myself"

a. Stop the client from leaving the unit

Male nurse swings on female nurse for pushing him out of the way of a gurney. What is the kind of abuse?

abused by mother as a child

patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact healthcare provider before giving

acetaminophen

patient in corner with paranoid symptoms, staring and watching you. They refused to communicate with you. What do you do?

ask simple questions

receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take Blood alcohol level-

ask the client about alcohol quantity, frequency, and time of the last drink.

A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first

ask the client to identify problems that have occurred during the last month

A patient is being admitted for drug overdose. She says the reason she is using drugs is because of a recent breakup of an intimate relationship? what does the nurse do first

ask the patient if they feel as if they have a plan of suicide

The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?

b. Benzotropine (Cogentin).

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?

b. Prior to giving the next dose, notify the physician of the symptoms.

A 26-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells her the nurse," please let me leave because the secret police are after me." Which response is best for the nurse

come with me to your room and I will sit with you

A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death

becomes the faculty sponsor for students against drunk driving (SADD)

a bipolar patient has stopped taking an antipsychotic. What other medication should the nurse expect to be D/C

benzotropine (Congentin)

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

c. CNS stimulation will be reduced.

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?

c. Chlordiazepoxide (Librium).

Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

c. Pepperoni and cheese pizza, tossed salad, and soda.

A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement

consult with the healthcare provider about reducing the dosage

TOOL assessment

cut down on your drinking, people annoyed you, felt bad or guilty about your drinking, drink first thing in the morning hangover (Eye-opener)

A male patient got divorced a year ago, lost his job, and recently suffered from a break up. What is his reason for his recent depression?

feelings of loss

A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care

delay business decisions until his mania subsides

A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate

delusions of persecution

patient being discharged

discuss feelings of discharge

Woman comes into ED having been raped by her date. What should the nurse document?

document she stated "I was raped by my date"

Lithium level 1.5. What do you tell the client who had a recent suicide attempt after seeing him become very anxious after hearing his Lithium levels?

drink 2-3L of water in 24 hours

antidepressant side effects

dry mouth, blurred vision, constipation

Anorexic pt asking to work as a cook what is the nurse best response?

encourage to work as a secretary

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship

explore the client's feelings related to discharge

aspiration due to caustic material related to suicide attempt

ineffective breathing pattern

no TV in room tell patient

it is important to be out of your room and talking to others

A patient has possessions she doesn't trust anyone to hold because she thinks they will steal them. How does the nurse establish trust?

make sure to talk short comments every now and then to her

What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks

not attempt to commit suicide

A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first

observe the client in the chair

knee surgery post op and diaphoretic and visual hallucinations

obtain vital signs

Alcohol-Pancreatitis health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN

pancreatitis

Anger Management Give the client

permission to be angry

A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function e²ectively. What action should the nurse take

plan a list of activities to be carried out daily.

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?

remain alcohol free for 12 hours prior to the first dose

Client is increasing getting aggressive

remove other pts to another area

A nurse is changing a dressing on a bipolar patient's stomach from self-inflicting knife wound. What is the nurse's best approach?

showing no signs of being judgmental

A patient who has been on an antidepressant for 2 weeks. What should you watch for?

suicidal attempts

one on one session and nurse begins to get angry at patient

terminate session