Mental Health-Practice questions exam 2

What percentage of Americans will have a diagnosable mental disorder in their lifetime? a. 33% b. 50% c. 25% d. 30%

a. 33%

Nurse jones decides to respect family wishes and not tell the client of his terminal status because that would bring the most happiness to the most people. Which of the following ethical theories is considered in this decision? a. Utilitarianism b. Kantianism c. christian ethics d. ethical egoism

a. Utilitarianism

Sam has a diagnosis of major depression. After an unsuccessful trial of antidepressant medication, Sam's physician has hospitalized Sam for a course of ECT treatments. Sam says to the nurse on admission, "I don't want to end up like McMurphy in One Flew Over the Cuckoo's Nest! I'm scared!" Sam's priority nursing diagnosis at this time would be: a. anxiety related to deficient knowledge about ECT b. risk for injury related to risks associated with ECT c. Deficient knowledge related to negative media presentation of ECT d. acute confusion related to side effects of ECT

a. anxiety related to deficient knowledge about ECT

A client with depression has just been prescribed the antidepressant phenelzine (Nardil). She says to the nurse, "the doctor says i will need to watch my diet while i'm on this medication. What foods should I avoid?" Which of the following is the correct response by the nurse? a. bleu cheese, red wine raisins b. black beans, garlic, pears c. pork, shellfish, egg yolks d. milk, peanuts, tomatoes

a. bleu cheese, red wine, raisins

In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? a. risk for injury r/t excessive hyperactivity b. disturbed sleep pattern r/t manic hyperactivity c. Imbalanced nutrition, less than body requirements, r/t inadequate intake d. situational low self-esteem r/t embarrassment secondary to high risk behaviors

a. risk for injury r/t excessive hyperactivity according to Maslow's hierarchy of needs, maintaining client safety is always a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.

a client has just been admitted to the psychiatric unit with a diagnosis of MDD. Which of the following behavioral manifestations might the nurse expect to assess? (select all that apply) a. slumped posture b. delusional thinking c. feelings of despair d. feels best early in the morning and worse as the day progresses e. anorexia

a. slumped posture b. delusional thinking c. feeling of despair e. anorexia"

Which of the following describe advantages to electronic health records (EHRs)? select all that apply a. they reduce redundancy of information b. they reduce issues regarding privacy c. they decrease charting time d. they facilitate communication between disciplines

a. they reduce redundancy of information c. they decrease charting time d. they facilitate communication between disciplines

Which of the following individuals is at highest risk for suicide? a. Nancy, age 33, asian american, catholic, middle socioeconomic group, alcoholic b. John, age 72, white, Methodist, low socioeconomic group, diagnosis of metastatic cancer of the pancreas c. Carol, age 15, African American, Baptist, high socioeconomic group, no physical or mental health problems d. Mike, age 55, Jewish, middle socioeconomic group, suffered myocardial infarction a year ago

b. John, age 72, white, Methodist, low socioeconomic group, diagnosis of metastatic cancer of the pancreas

Success of long-term psychotherapy with Theresa (who attempted suicide following a breakup with her boyfriend) could be measured by which of the following behaviors? a. Theresa has a new boyfriend b. Theresa has increased sense of self-worth. c. Theresa does not take antidepressants anymore d. Theresa told her boyfriend how angry she was with him for breaking up with her.

b. Theresa has an increased sense of self-worth

The nurse assists the physician with ECT on his client who has refused to give consent. With which of the following legal actions might the nurse be charged because of this nursing action? a. assault b. battery c. false imprisonment d. breach of confidentiality

b. battery

A nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physical and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? a. libel b. battery c. assault d. slander e. false imprisonment

b. battery c. assault e. false imprisonent

Atropine sulfate is administered to a client receiving ECT for what purpose? a. to alleviate anxiety b. to decrease secretions c. to relax muscles d. as a short-acting anesthetic

b. to decrease secretions

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. Which lithium level is most consistent with these symptoms? a. 1.2 mEq/L b. 0.5 mEq/L c. 2.5 mEq/L d. 3.9 mEq/L

c. 2.5 mEq/L

People with mental health disorders die, on average, how many years before the general population? a. 20 b. 30 c. 25 d. 35

c. 25

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at nights and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? a. why do you believe this? b. tell me more about the details of your belief c. I hear what you are saying but I don't share your belief d. If you want to sleep in another room, I can get you a room of your own.

c. I hear what you are saying but I don't share your belief

Nurse Jones decides to tell the client of his terminal status because she believes it is her duty to do so. Which of the following ethical theories is considered in this decision? a. natural law theories b. ethical egosim c. kantianism d. utilitarianism

c. Kantianism

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Theresa says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll choose a no-fail method." Which is the best response by the nurse? a. "You are safe her. We will make sure nothing happens to you." b. "You're just lucky your roommate came home when she did." c. "What exactly do you plan to do?" d. "I don't understand. You have so much to live for."

c. What exactly do you plan to do?

Theresa, age 27, was admitted to the psychiatric unit from the medical intensive care unit where she was treated for taking a deliberate overdose of her antidepressent medication, trazodone (Desyrel). She says to the nurse, "My boyfriend broke up with me. We had been together for 6 years. I love him so much. I know I'll never get over him." Which is the best response by the nurse? a. "You'll get over him in time, Theresa." b. "Forget him. There are other fish in the sea." c. "You must be feeling very sad about your loss." d. "Why do you think he broke up with you, Theresa?"

c. You must be feeling very sad about your loss

A client with schizophrenia says to the nurse, "will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse? a. Where is she? I'll talk to her. b. The Grand Duchess? Well, I'm the queen and I'll order her to stay away from you c. You will be safe here. You will be able to think more clearly once your medication starts to work. d. I can seen no Grand Duchess. Just trust me on that.

c. You will be safe here. You will be able to think more clearly once your medication starts to work.

When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? a. Provide large motor activities to relieve the client's pent-up tension b. Administer a dose of prn chlorpromazine to keep the client calm c. call for sufficient help to control the situation safely d. convey to the client that his behavior is unacceptable and will not be permitted.

c. call for sufficient help to control the situation safely

A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. With which of the following legal actions might the nurse be charged because of this nursing action? a. assault b. battery c. false imprisonment d. breach of confidentiality

c. false imprisonment

Nursing diagnoses are prioritized according to: a. degree of potential for resolution b. legal implications associated with nursing interventions c. life-threatening potential d. client and family requests

c. life-threatening potential

Succinylcholine is administered to a client receiving ECT for what purpose? a. to alleviate anxiety b. to decrease secretions c. to relax muscles d. as a short-acting anesthetic

c. to relax muscles

Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: a. "That's ridiculous, Clint. No one is going to hurt you." b. "The CIA isn't interested in people like you, Clint." c. "Why do you think the CIA wants to kill you?" d. "I know you believe that, Clint, but it's really hard for me to believe."

d. "I know you believe that, Clint, but it's really hard for me to believe.

The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the health care provider (HCP) immediately. Which is the appropriate nursing intervention? a. infor the client that the behavior is unacceptable b. tell the client to wait in his room until report is over c. tell the client that the HCP will be called as soon as report is over d. Offer to assist the client to an examination room until the HCP can be notified

d. Offer to assist the client to an examination room until the HCP can be notified.

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Freudian psychoanalytic theory would explain Theresa's suicide attempt in which of the following ways? a. she feels hopeless about her future without her boyfriend b. Without her boyfriend, she feels like an outsider with her peers c. She is feeling intense guilt because her boyfriend broke up with her. d. She is angry at her boyfriend for breaking up with her and has turned the anger inward on herself

d. She is angry at her boyfriend for breaking up with her and has turned the anger inward on herself

Education for the client who is taking MAOIs should include which of the following? a. fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity b. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks c. short-term use, possible tolerance to beneficial effects, careful tapering of the drug at end of treatment d. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification

d. Tyramine-restricted diet, prohibitive concurrent use of OTC medications without physician notification

Joe is very restless and is pacing a lot. The nurse says to joe, "if you don't sit down in the chair and be still, I'm going to put you in restraints!" with which of the following legal actions might the nurse be charged because of this nursing action? a. defamation of character b. battery c. breach of confidentiality d. assault

d. assault

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Because Benztropine was ordered on a prn basis which of the following assessments by the nurse would convey a need for this medication? a. The client's level of agitation b. The client complains of a sore throat c. the client's skin has a yellowish cast d. the client develops tremors and a shuffling gait

d. the client develops tremors and a shuffling gait

The primary focus of family therapy for clients with schizophrenia and their families is: a. to discuss concrete problem solving and adaptive behaviors for coping with stress b. to introduce the family to others with the same problem c. to keep the client and family in touch with the health care system d. to promote family interaction and increase understanding of the illness.

d. to promote family interaction and increase understanding of the illness

John is a client at the mental health clinic. He is depressed, has been expressing suicidal ideations, and has been seeing the psychiatric nurse every 3 days. He has been taking 100 mg of setraline daily for about a month, receiving small amounts of the medication from his nurse at each visit. Today he comes to the clinic in a cheerful mood, much different than he seemed just 3 days ago. How might the nurse assess this behavioral change? a. the setraline is finally taking effect b. he is no longer in need of antidepressant medication c. he has completed the grief response over loss of his wife d. he may have decided to carry out his suicide plan e. help her to identify stressors in her life that precipitate crises.

e. help her identify stressors in her life that precipitate crises.

Guidelines relating to "duty to warn" state that a therapist should consider taking action to warn a third party when his or her client: (select all that apply) a. Threatens violence toward another individual b. identifies a specific intended victim c. is having command hallucinations d. reveals paranoid delusions about another individual

a. threatens violence toward another individual b. identifies a specific intended victim

Which of the following conditions is considered to be the only absolute contraindication for ECT? a. increased intracranial pressure b. recent MI c. sever underlying hypertension d. congestive heart failure

a. increased intracranial pressure

A client whose husband died 6 months ago is diagnosed with MDD. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a. "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response." d. "just think about the good times that you had while he was alive."

c. those feelings are normal part of the grief response

S.T. is a 15 year old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5 ft. 5 in. tall and weighs 82 lbs. She was elected to the cheerleading squad for the fall but states that she is not as good as the others on the squad. The treatment team had identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be appropriate for S.T.? a. social isolation b. disturbed body image c. low self-esteem d. imbalanced nutrition: less than body requirements

a. social isolation b. disturbed body image c. low self-esteem

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? a. increase socialization of the client with peers b. avoid whispering or laughing in front of the client c. educate the client about social supports in the community d. Have the client sign a release of information for assessment purposes

b. Avoid whispering or laughing in front of the client

Which of the following best describes the average number of ECT treatments given and then timing of administration? a. one treatment per month for 6 months b. one treatment every other day for a total of 6 to 12 treatments c. One treatment three times per week for a total of 20-30 treatments d. one treatment every day for a total of 10-15 treatments

b. One treatment every other day for a total of 6 to 12 treatments

A client diagnosed with catatonic stupor is lying on the bed, hidden under the sheets, in a fetal position. Which appropriate action should the nurse should take? a. ask direct questions to encourage talking b. sit beside the bed in silence, with occasional open-ended questions c. leave the client alone, but check on her every 30 minutes d. Take the client into the dayroom so she can interact with the others.

b. Sit beside the bed in silence, with occasional open-ended questions.

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side stops talking midsentence, and listens intently. The nurse recognizes these behaviors as a symptom of the client's illness. The most appropriate nursing intervention for this symptom is to: a. ask the client to describe his physical symptoms b. Ask the client to describe what he is hearing c. administer a dose of benztropine d. call the physician for additional orders

b. ask the client to describe what he is hearing

The nurse is preparing a client for ECT. The family of the client asks the nurse about this treatment. The nurse responds, knowing that which statements are accurate regarding this treatment? Select all that apply a. the average series involves 6 to 12 treatments b. memory loss will occur but will resolve with time c. some confusion is normal after the procedure d. this treatment is a permanent cure to the condition e. this treatment is tried before the use of medications

a. the average series involves 6 to 12 treatments b. memory loss will occur but will resolve with time c. some confusion is normal after the procedure

Nurse Jones decides to go against family wishes and tell the client of his terminal status because that is what she would want if she were the client. Which of the following ethical theories is considered in this decision? a. Kantiansim b. christian ethics c. Natural law theories d. ethical egoism

b. christian ethics

The admitting nurse asks the client what precipitating factors, such as recent life changes, have contributed to the need for hospitalization. The client responds by saying, "Change...change the range, manage the change." The nurse should recognize this response as an example of which of the following? a. flight of the ideas b. clanging c. perseveration d. word salad

b. clanging

The primary goal in working an actively psychotic, suspicious client would be to : a. promote interaction with others b. decrease his anxiety and increase trust c. improve his relationship with his parents d. encourage participation in therapy activities

b. decrease anxiety and increase trust

ECT is thought to effect a therapeutic response by: a. stimulation of the CNS b. Decreasing the levels of acetylcholine and monoamine oxidase c. Increasing the levels of serotonin, norepinephrine, and dopamine d. altering sodium metabolism within nerve and muscle cells

c. increasing the levels of serotonin, norepinephrine, and dopamine

ECT is most commonly prescribed for: a. bipolar disorder, manic b. paranoid schizophrenia c. major depression d. Obsessive compulsive disorder

c. major depression

The nurse identifies the primary nursing diagnosis for theresa as Risk for suicide related to feeling of hopelessness from loss of relationship. Which is the outcome criterion that would most accurately measure achievement of this diagnosis? a. the client has experienced no physical harm to herself b. The clients sets realistic goals for herself c. the client expresses some optimism and hope for the future d. The client has reached a stage of acceptance in the loss of the relationship with her boyfriend

a. the client has experienced no physical harm to herself

A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention? a. Turn off the television b. Walk with the client around the unit c. Discuss the possible hallucinatory triggers d. help his call his mother

a. turn off the television

In teaching client about his antidepressant medication, fluoxetine, which of the following would the nurse include? (select all that apply) a. Don't eat chocolate while taking this medication b. Keep taking this medication, even if you don't feel it is helping. It sometimes take a while to take effect. c. Don't take this medication with the migraine drugs "triptans" d. Go to the lab each week to have your blood drawn for therapeutic level of this drug e. this drug causes a high degree of sedation, so take it just before bedtime

b & c

For which of the following reasons may an individual be considered gravely disabled? (select all that apply) a. A person, because of mental illness, cannot fulfill basic needs b. a mentally ill person is in danger of physical harm based on inability to care for self c. a mentally ill person lacks the resources to provide the necessities of life d. A mentally ill person is unable to make use of available resources to meet daily living requirements.

a. A person, because of mental illness, cannot fulfill basic needs b. A mentally ill person is in danger of physical harm based on inability to care for self d. A mentally ill person is unable to make use of available resources to meet daily living requirements

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. a. communicate expected behaviors to the client b. ensure that the client know that they are not in charge of the nursing unit c. assist the client in identifying ways of setting limits on personal behaviors d. follow through about the consequences of behavior in a nonpunitive manner e. enforce rules by informing the client that they will not be allowed to attend therapy groups f. Have the client state the consequences for behaving in ways that are viewed as unacceptable

a. communicate expected behaviors to the client c. assist the client in indentifying ways of setting limits on personal behaviors d. follow through about the consequences of behavior in a nonpunitive manner f. have the client state the consequences for behaving in ways that are viewed as unacceptable

Clint a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of a : a. delusion of presecution b. delusion of reference c. delusion of control or influence d. delusion of grandeur

a. delusion of persecution

Some biological factors may be associated with the predisposition to suicide. Which of the following biological factors have been implicated? a. genetics and decreased levels of serotonin b. heredity and increased levels of norepinephrine c. temporal lobe atrophy and decreased levels of acetylcholine d. structural alterations of the brain and increased levels of dopamine

a. genetics and decreased levels of serotonin

The nurse is using nursing process to care a suicidal client. Which is a part of the diagnosis step of the nursing process? a. identifies nursing diagnosis: risk for suicide b. notes that clients family reports recent suicide attempt c. prioritizes the necessity for maintaining a safe environment for the client d. Obtains a short-term contract from the client to seek out staff if feeling suicidal

a. identifies nursing diagnosis: risk for suicide

The goal of the cognitive therapy with depressed clients is to: a. Identify and change dysfunctional patterns of thinking b. resolve the symptoms and initiate or restore adaptive family functioning c. after the neurotransmitters that are creating the depressed mood. d. provide feedback from peers who are having similar experiences

a. identify and change dysfunctional patterns of thinking

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the planning step of the nursing process? a. prioritizes the necessity for maintaining a safe environment for the client b. determines if nursing interventions have been appropriate to achieve desired results c. obtains a short-term contract from the client to seek out staff if feeling suicidal d. establishes goal of care: client will not harm self during hospitalization

a. prioritizes the necessity for maintaining a safe environment for the client

Which of the following interventionns are appropriate for a client on suicide precautions? (select all that apply) a. remove all sharp objects, belts, and other potentially dangerous articles form the client's environment b. Accompany the client to off-unit activities c. Obtain a promise from the client that she will not do anything to harm herself for the next 12 hours d. Put all of the client's possessions in storage and explain to her that she may have them back when she is off suicide precautions

a. remove all sharp objects, belts, and other potentially dangerous articles from the client's environment b. Accompany the client to off-unit activities c. obtain a promise from the client that she will not do anything to harm herself for the next 12 hours

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the evaluation stop of the nursing process? a. prioritizes the necessity for maintaining a safe environment for the client b. determines if nursing interventions have been appropriate to achieve desired results c. obtains a short-term contract fro the client to seek out staff if feeling suicidal d. establishes goal of care: client will not harm self during hospitalization

b. determines if nursing interventions have been appropriate to achieve desired results

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? a. I don't believe this is true b. do you feel afraid that people are trying to hurt you? c. the guards are not out to kill you d. What makes you think the guards were sent to kill you?

b. do you feel afraid that people are trying to hurt you?

Tony, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Tony is to : a. give him an injection of throazine b. ensure a safe environment for him and others. c. place him in restraints d. order him a nutritious diet

b. ensure a safe environment for him and others

The nurse is planning to instruct a mental health client an his or her family about the importance of medication compliance. The nurse should plan for which interventions that are associate with increased compliance? Select all that apply. a. giving all medications just once per day b. including the family in the medication planning process c. providing the client with the injectable , long-acting form of the medication available d. working with psychiatrist to find the right medication at the right dose e. giving the patient prescriptions with 1 year worth of refills

b. including the family in the mediation planning process c. providing the client with the injectable long-acting form of the medication available d. working with psychiatrist to find the right medication at the right dose.

A newly admitted depressed client isolates herself in her room and just sits and stares into space. How best might the nurse begin an initial therapeutic relationship with this client? a. Say, "Come with me, I will go with you to group therapy b. make frequent short visits to her room and sit with her. c. offer to introduce her to the other clients

b. make frequent short visits to her room and sit with her.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the assessment step of the nursing process? a. identifies nursing diagnosis: risk for suicide b. notes that clients family reports recent suicide attempt c. prioritizes the necessity for maintaining a safe environment for the client d. obtains a short term contract from the client to seek out staff if feeling suicidal

b. notes that clients family reports recent suicide attempt

Which of the following statements is (are) correct regarding the use of restraints? (select all that apply) a. restraints may never be initiated without a physicians order b. orders for restraints must be reissued by a physician every 2 hours for children and adolescents c. clients in restraints must be observed and assessed every hour for issues regarding circulation, nutrition, respiration, hydration, and elimination d. an in-person evaluation must be conducted within 1 hour of initiating restraints.

b. orders for restraints must be reissued by a physician every 2 hours for children and adolescents d. an in-person evaluation must be conducted within 1 hour of initiating restraints

The physician order setraline (zoloft) 50 mg PO bid for margeret, a 68 year old woman with MDD. After 3 days of taking the medicaiton, Margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better." What is the most appropriate response by the nurse? a. "cheer up, Margaret. You have so much to be happy about." b. "sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms." c. "I'll report that to the physician, Margaret. maybe he will order something different." d. "Try not to dwell on your symptoms, Margaret. Why don't you join the others in the dayroom?"

b. sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms.

Sam who has been hospitalized for ECT treatments, says to the nurse on admission, "I don't want to end up like McMurphy in one flew over the cuckoos nest i'm scared. which of the folloiwng statements would be most appropriate by the nurse in response to Sam's expression of concern? a. "I guarantee you won't end up like McMurphy, Sam." b."The doctor know what he is doing. There's nothing to worry about." c. "I know you are scared, Sam, and we're going to talk about what you can expect from the therapy." d. "I'm going to stay with you as long as you are scared."

c. I know you are scared, sam, and we're going to talk about what you can expect from the therapy

A nurse is administering the medication thioridazine hydrochloride to a pt. 4 times a day. The client reports hand tremors, drooling, and restlessness. Which of the following is an innapproriate nursing action? a. Administer Diazepam 5 mg as ordered b. chart observations and reassure client that these reactions are normal c. administer benztropine Mesylate 1 mg as ordered d. Encourage deep breathing and relaxation

c. administer benztropine mesylate 1 mg as ordered

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing: a. somatic delusions b. catatonic stupor c. auditory hallucinations d. pseudoparkinsonism

c. auditory hallucinations

A bipolar client is now engaged in group therapy sessions. She begins yelling at another client during the therapy session and screams, "I can't listen to this. You people are no different from the ones at home." The client stands up and tips the chair over backward. What is the nurse's immediate action? a. inform the client that she must leave the group b. explore the other client's responses to the behavior c. firmly reinforce group rules to the client, stating that yelling is not allowed in the group d. call security to come to the group session

c. firmly reinforce group rules to the client, stating that yelling is not allowed in the group

In determining degree of suicidal client, the nurse assesses the following behavioral manifestations: severly depressed, withdrawn, statements of worthlessness, difficulty accomplishing activities of daily living no close support systems. The nurse identifies the client's risk for suicide as: a. low b. moderate c. high d. unable to determine

c. high

The nurse is using nursing process to care for a suicidal client. which of the following nursing actions is a part of the implementation step of the nursing process? a. prioritizes the necessity for maintaining a safe environment for the client b. determines if nursing interventions have been appropriate to achieve desired results c. obtains a short-term contract from the client to seek out staff if feeling suicidal d. establishes goal of care: client will not harm self during hospitalization.

c. obtains a short-term contract from the client to seek out staff if feeling suicidal

A mental health nurse is assigned to care for a client with a diagnosis of acute schizophrenia. The nurse should use which approach when planning care for this client? a. allow the client to set the goals for the plan of care b. let the client act out initially, and use the quiet room and restraints as needed c. provide assistance with grooming and nutrition until the client's thinking has cleared d. repeatedly point out inconsistencies in the client's communication during initial treatment.

c. provide assistance with grooming and nutrition until the clients thinking has cleared

Margaret age 68 is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, has lost weight and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with MDD. The priority nursing diagnosis for Margaret would be: a. imbalanced nutrition: less than body requirements b. complicated grieving c. risk for suicide d. social isolation

c. risk for suicide

Attempting to calm an angry client by using "talk therapy" is an example of which of the following clients' rights? a. The right to privacy b. the right to refuse medication c. the right to the least-restrictive treatment alternative d. the right to confidentiality

c. the right to the least-restrictive treatment alternative

the nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Why is chlorpromazine ordered? a. to reduce extrapyramidal symptoms b. to prevent neuroleptic malignant syndrome c. to decrease psychotic symptoms d. to induce sleep

c. to decrease psychotic symptoms

The priority nursing intervention before starting ECT is to: a. take vital sign and record b. have the patient void c. administer succinylcholine d. ensure that the consent form has been signed

d. ensure that the consent form has been signed

A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? a. Place the client in seclusion for 30 minutes b. tell the client that the behavior is inappropriate c. tell the client that her telephone privileges will be revoked for 24 hours d. Escort the client to her room, with the assistance of other staff

d. escort the client to her room, with the assistance of other staff

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is part of the outcome identification step of the nursing process? a. prioritizes the necessity for maintaining a safe environment for the client b. determines if nursing interventions have been appropriate to achieve desired results c. obtains a short-term contract from the client to seek out staff if feeling suicidal d. establishes goal of care: client will not harm self during hospitalization

d. establishes goal of care: client will not harm self during hospitalization

S.T. is a 15 year old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5 ft. 5 in. tall and weighs 82 lbs. She was elected to the cheerleading squad for the fall but states that she is not as good as the others on the squad. The treatment team had identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be the priority diagnosis for S.T.? a. social isolation b. disturbed body image c. low self-esteem d. imbalanced nutrition: less than body requirements

d. imbalanced nutrition: less than body requirements

The nurse is planning relapse prevention information for a client with schizophrenia who is being discharged. The nurse understands that it is important to ensure which primary intervention in the plan whenever possible? a. Facilitating weekly maintenance with the client b. Having the client restate discharge goals and strategies c. Stressing the importance of the client's compliance with the treatment plan. d. including the client's support system in the teaching

d. including the client's support system in the teaching

A client has been taking a typical antipsyhotic for 6 years, and the doctor is gradually tapering off the dosage. During this process, the nurse should watch closely for which of the following early manifestations of tardive dyskinesia? a. Jerky, choreiform movements of the upper extremities b. Slow, involuntary athetoid movements of the arms and legs c. tonic contractions of the neck and back d. involuntary grimacing, lip smacking, and tongue protrusion

d. involuntary grimacing, lip smacking, and tongue protrusion

The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which medical diagnosis, if noted on the client's record, would indicate a need to contact the HCP scheduled to perform the ECT? a. diabetes mellitus b. hyperthyroidism c. peripheral vascular disease d. recent myocardial infarction

d. recent myocardial infarction

The most common side effects of ECT are: a. permanent memory loss and brain damage b. fractured and dislocated bones c. myocardial infarction and cardiac arrest d. temporary memory loss and confusion

d. temporary memory loss and confusion