Mental health - Quiz #1

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a near panic state. The client states, "My partner just left me. I am a wreck." What should the nurse do to help the client cope with this loss? Select all that apply

Identify the client's support systems and encourage the client to talk about the situation

A Latino client with schizophrenia is admitted to a mental health unit in an aggravated and disheveled state after failing to take prescribed medications for the last 5 days. When developing a plan of care that incorporates the client's cultural background, the nurse gives priority to:

Inclusion of the family in the plan of care with the client's permission

A client is receiving lithium. What is an important nursing intervention while this medication is being administered?

Monitor the client's drug blood level regularly

A nurse is teaching clients about dietary restrictions when taking a monoamine oxidase inhibitor (MAOI). What response does the nurse tell them to anticipate if they do not follow these restrictions?

Occipital headaches

What is the most important tool a nurse brings to the therapeutic nurse-client relationship?

Oneself and a desire to help

A health care provider orders "Restraints prn" for a client who has a history of violent behavior. What is the nurse's responsibility concerning this order?

Recognize that prn orders for restraints are unacceptable

What is the priority goal when planning care for a client in crisis?

Restoring the client's psychologic equilibrium

A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before. "What is the nurse's best reply?

"How do you feel about having a male nurse?"

What is an initial client objective in relation to anger management?

Taking responsibility for the hostile behavior

A physician is admitted to the psychiatric unit of a community hospital. The client, who was restless, loud, aggressive, and resistive during the admission procedure, states, "I will take my own blood pressure." What is the nurse's most therapeutic response?

"I am sorry, but I cannot allow that because I must take your blood pressure"

An extremely anxious client enters a crisis center and asks a nurse for help. Which response best reflects the nurse's role in crisis intervention?

"I will be here for you to help you figure things out"

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply.

"I would like to end it all with sleeping pills" and "voices say it is okay for me to kill all prostitutes"

A nurse leads an assertiveness training program for a group of clients. Which client statement demonstrates that the treatment has been effective?

"It annoys me when people call me 'Dearie,' so I told him not to do it anymore"

A parent of a 13-year-old adolescent who was recently diagnosed with Hodgkin disease tells a nurse, "I don't want my child to know the diagnosis." How should the nurse respond?

"Let's talk about your feeling regarding your child's diagnosis"

During a group meeting a client tells everyone, "I am afraid of my impending discharge from the hospital." What is the most appropriate response by the nurse facilitator?

"Maybe others in the group have similar feelings that they would share"

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, a nurse expresses disgust that the woman returns to the same situation. What is the nurse manager's best response?

"Most woman attempt to leave about six times before they are able to do so"

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because "I have nothing to talk about." What is the best response by the nurse?

"You feel you will not be accepted unless you have something to say?"

When assisting clients to cope with a crisis, the health care provider should follow the principles of intervention. Place the following interventions in order of their priority.

1. Intervene immediately, 2. Stabilize the client, 3. facilitate understanding of the event, 4. Use the available resources, 5. Encourage self-reliance

A depressed client has been prescribed a tricyclic antidepressant. How long should the nurse inform the client it will take before noticing a significant change in the depression?

2 to 4 weeks

A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response?

A client is allowed to consent or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs

Which approaches should a nurse use during crisis intervention? Select all that apply.

Active and goal-directed

Chlordiazepoxide (Librium) 100 mg PO per hour is pre- scribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client had 300 mg in 3 hours and is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?

Administer chlordiazepoxide as indicated by the client's CIWA score

A client with the diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next?

Arrange a unit meeting to discuss what just happened

What is the most important information a nurse should teach to prevent relapse in a client with a psychiatric illness?

Follow the prescribed medication regimen

What is the most difficult initial task when developing a nurse-client relationship?

Developing an awareness of self and the professional role in the relationship

A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before assessing a child's response to a crisis

Developmental level of the child

A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the 6-week course of treatment?

Elimination of benzodiazepines for nighttime sedation

A client is diagnosed with a borderline personality disorder. What is a realistic initial intervention for this client?

Establish clear boundaries

What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be re-hospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks?

Fluphenazine

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when administering this medication?

Have the client checked for increased intraocular pressure and teach about symptoms of glaucoma

Among members of the nursing team, which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply.

Health promotion, case management, and treating human responses

Which statement best describes the practice of psychiatric nursing?

Helps people with present or potential mental health problems

A client in the hyperactive phase of a mood disorder, bipolar type, is receiving lithium. A nurse identifies that the client's lithium blood level is 1.8 mEq/L. What is the most appropriate nursing action?

Hold the drug and notify the health care provider immediately because the blood lithium level may be toxic

At a group therapy session, a client tearfully tells the other members, "I just lost my job this week." What is the nurse leader's most appropriate response?

Quietly observe how the group responds to the client's statement

A nurse is caring for a client who abruptly withdrew from barbiturate use. What should the nurse anticipate that the client may experience?

Seizures

A 44-year-old client is unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis reflects this situation?

Situational

A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication?

Staying in the sun

A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group?

Support

A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting out behavior?

Teaching relaxation

Which is the most important assessment data for a nurse to gather from the client in crisis

The client's perception of the circumstances surrounding the crisis

A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" or if the mother's name is mentioned. What does the nurse conclude about this behavior?

The co-worker may need help with grieving

A nurse educator is leading a class on supporting middle- aged adults who are experiencing midlife crisis. What should the nurse include as the most significant factor in the development of this type of crisis?

The perception of their life situation

A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symptoms? Select all that apply.

There is more interest shown in unit activities and the client performs activities of daily living independently

A nurse reminds a client that it is time for group therapy. The client responds by yelling at the nurse, "You are always telling me what to do, just like my father!" What defense mechanism is the client using?

Transference

A nurse administers an antipsychotic to a client. For which common manageable side effect should the nurse assess the client?

Unintentional tremors