MH- Final Review

Which nursing intervention will have the greatest initial impact on establishing a therapeutic milieu with a newly admitted client?

Including a discussion on the unit rules as a part of the admission process

The nurse is reviewing a plan of care for a client diagnosed with ADHD. The child is prescribed Strattera. The nurse determines that the medication is effective based on which outcome?

Increased attention on homework

When interviewing a psychiatric client, which of the following nonverbal behaviors should the nurse be careful to avoid?

Leaning back with arms crossed

When providing nursing care for a child exhibiting suicidal ideations, which intervention should take priority for this client?

Maintaining a safe environment

Which assessment data support the nurse's evaluation that a 10 year old diagnosed with attention deficit/hyperactivity disorder (ADHD) has demonstrated progress toward achieving a long-term goal specific to this disorder?

Parent reports child earned three Bs and one A on the report card

A client is being treated under court order for a sexual offense. Which outcome is of particular importance to this client's plan of care?

Participates and cooperates in a treatment plan to change behavior

A mental health nurse teaches clients how to recognize what triggers their anger responses. The nurse performs this teaching about triggers for what reason?

Provides the opportunity to gain control of their anger

To foster a sense of safety in a client demonstrating paranoid behavior, which nonverbal technique should the nurse implement?

Respecting an extended area of personal space when interacting with the client

A client presents at the clinic with a possible diagnosis of hypoactive sexual desire disorder. The nurse should assess for this sexual disorder by asking the client:

how many times he has sex in a month

A young woman, aged 25, has come to the clinic for a premarital physical examination. She tells the nurse that she is a virgin and really does not want to have sex. The client says that she has always been taught that sex is "dirty" and "nice girls" did not do things like that. She wonders what she will do after her wedding. Which nursing diagnosis would the nurse use when writing this client's care plan?

ineffective coping, individual, related to ones sexuality

A woman confides to the nurse that she does not want any more children and no longer desires to have sex. To best explore the client's current disinterest in sex, which assessment question should the nurse ask?

is sex associated with unpleasant memories for you?

A nurse is using hand gestures and facial expressions when communicating with a client. Which technique is the nurse using?

kinesics

Which statement demonstrates the nurses use of focusing when communicating with a client about relationships with family members?

lets get back to how you feel about your sons decision to leave school

Which of the following is a component of the clients mental status nursing assessment?

mood & affect

Which intervention would be effective in refocusing the attention of a client diagnosed with an eating disorder?

restricting time devoted to meals to 30 minutes

A child diagnosed with oppositional-defiant disorder refuses to conform to curfew rules set by his parents. Which interventions would the nurse reinforce with the parents to do first?

setting a reasonable limit with consequences

A young girl confides to the nurse that she has recently become sexually active but that "having sex doesn't feel good." Which type of disorder should the nurse suspect is involved in this client's lack of pleasure in the sexual act?

sexual orgasmic

Which nursing diagnosis best addresses a paroled sexual offender's reluctance to engage in interpersonal relationships?

social isolation related to sexual beliefs and practices

To best manage the risk of relapse for the client diagnosed with a paraphilia disorder, the nurse includes which intervention in the client's plan of care?

taking a daily inventory of thought processes

Which characteristic is consistent with the diagnosis of enuresis

the child must be at least 5 years of age

A failure to utilize sounds or articulate syllables intelligibly during speech is the essential feature of the child diagnosed with speech sound disorder.

true

Domestic violence and abuse are patterns of behavior used by one person to control or have power over another through fear and intimidation with threats or acts of violence

true

In ID, cognitive impairment is seen is the delay of the individuals conceptual skills of language and reading, time, numbers, money and self-care deficits

true

Input from the clients family can provide information about family dynamics, any present turmoil or disruption within the family, and how the clients problem may be affecting other members of the family.

true

People who are easily frustrated and angered have a history of being irritable, touchy, and quick tempered from an early age.

true

To the person who is unable to see any other way of improving his or her present situation, suicide may seem to be a logical and rational solution

true

The nurse is assisting the client to overcome the fear of public places. The nurse and the client are in which phase of the therapeutic relationship?

working phase

Which long-term goal is especially appropriate for a child diagnosed with ADHD

Consistent decrease in disruptive and dangerous behaviors

Which nursing activity is directly associated with the evaluation phase of the nursing process for a client admitted with a diagnosis of acute situational depression?

Revising the clients plan of care to include daily behavioral therapy sessions

What response best teaches the client about the events and outcome expected with electroconvulsive therapy treatment?

A controlled seizure occurs that helps to restore a chemical balance in the brain

A client tells the nurse, "I really want to die." Which intervention would be the priority?

Assuring the client that he will not be left alone

A nurse asks a client, " Did i understand you correctly" The nurse is using which verbal communication technique

Clarification

When considering various client needs, which statement is the basis for prioritizing those needs?

Clients current problems have priority over those problems that may develop.

When considering various client needs, which statement is the basis for prioritizing those needs?

Clients perception of his or her problems determines his or her priority

A nurse is preparing a presentation for a group of parents in the local school district about learning disabilities. The nurse would describe which disability as being the most common learning disability?

Dyslexia

The parents of a teenager diagnosed with anorexia nervosa ask "Why do we need to attend family therapy?" How can the nurse best meet the needs of the child?

Explain that the sessions will help them see the connection between family behaviors and their teens eating habits

The nurse is managing care of a child diagnosed with a moderate intellectual disability. Which intervention is the priority when attempting to impact the childs ultimate ability to function independently?

Facilitate early enrollment in a specialized educational program

Basic lack of trust, low self-esteem, a poor sense of identity, little or no pleasure in sexual activity, and promiscuity are not common characteristics of the adult who was sexually abused by a parent (incest) as a child.

False

Client-specific interactions and actions in which boundaries are clarified should not be documented in the client medical record.

False

Monoamine neurotransmitters stored in a presynaptic compartments of neurons in the CNS include the chemical messengers epinephrine, dopamine and serotonin.

False

In the elderly or older adult, the half-life of a drug tends to decrease by as much as five to six times increasing the risk of toxicity.

False, increase

The nursing documentation for a client diagnosed with anorexia nervosa, restricting subtype notes that the client is now able to self-reflect and recognize the relationship between eating patterns and the disorder. This insight demonstrates the achievement of which treatment goal?

Guilt and shame over the previous behavior have been released

The nurse is caring for a 14-year-old diagnosed with an eating disorder. Which interview question focuses on the most relevant issue associated with family dynamics and the development of eating disorders?

How would you describe the relationship you have with your mother?

Which statement made by the nurse best demonstrates the concepts of empathy and objectivity when working with a client diagnosed with anger management issues?

I can see why you are so angry but throwing the chair is not an acceptable way to handle that anger.

A client tells the nurse, "The voices say that I am evil and I am going to be punished"Which of the following would be the most therapeutic response?

I dont hear the voices, but the words must be frightening you

Which statement by a 14 year old best supports the nurses suspicions that the teen is a victim of bullying

Some kids at my school can be really mean sometimes

A call is received by the crisis hotline with the person stating " I have a gun and I am going to shoot myself" Which level of lethality is demonstrated by this individual?

Suicidal gesture

Which statement by the nurse best demonstrates the necessary approach to the care of a client diagnosed with a sexually oriented disorder?

The management of a sexual dysfunction disorder is approached like any other dysfunction

Which of the following best describes the role of the nurse in the therapeutic milieu of a psychiatric unit?

The member of the treatment team who is responsible for management of the therapeutic milieu

Which statement by an individual with a history of anger management issues best demonstrates where anger and resentment originate?

The way I see it is that I was wronged and had the right to get angry

Which statement made by the nurse to a newly admitted client demonstrates an understanding of a therapeutic milieu?

This is a safe place for you to express your feelings without concern about how you will be accepted

Client specific interactions and actions in which boundaries are clarified should be documented in the client medical record

True

How does the nurse use communication to best effect mental health care for a client diagnosed with a mental illness?

Using therapeutic communication to build a trusting nurse-client relationship

The nurse is addressing the needs presented by a woman who has just left an abusive spouse. The nurse would initially focus on which area?

Working with the client to identify a safe place to live

A client who will be having several diagnostic tests the following day complains of being unable to sleep. When the client says, "I am so afraid something is really wrong with me" Which of the following responses would be most therapeutic?

You seem worried about the results of your tests. Would you like to talk about it?

The nurse is focused on creating a nursing plan of care for a client diagnosed with a chronic mental illness. Which statement made by the nurse demonstrates the best understanding of the guiding principle associated with achievement of care outcomes involving client-focused interventions?

a) " I value your opinions and suggestions concerning your treatment plan since it must be adapted to your personal needs in order to be successful.

Which interventions would be appropriate when using active listening? Select all that apply.

a) Allowing the nurse to model appropriate behaviors before responding b) Reviewing the client comments and behaviors before responding c) giving critical attention to verbal comments d) Attempting to understand the clients perception of the situation

The nurse is completing a psychosocial assessment. Which information would reflect objective data gathered during a clients psychosocial assessment? Select all that apply.

a) Awareness c) motor activity d) affect e) judgment

A client has received teaching about the process of anger. The nurse determines that the teaching was successful based on which client statement?

a) I know its natural to be angry but I cant keep hurting my children like I do

Which intervention is the sole responsibility of a LPN working on a psychiatric unit? select all that apply

a) Monitoring side effects when a client is prescribed new medication b) Participating in therapeutic communication with clients

A nurse is gathering data about a client potential for risk domestic violence. When reviewing the clients history, which information would the nurse identify as being important? Select all that apply

a) Reported. "My dad beat us with a belt when we didnt obey him". b) Made the Statement, "Women need to stay home and raise the children" c) Has been arrested for intentionally breaking the neighbors windows. e) Has a history of drug abuse

A nurse is reading a journal article about Therapeutic communications. The nurse demonstrates understanding of the information by identifying which statement as reflecting the topic? Select all that apply

a) The focus is on the client c) It requires practice d) It is planned by the client

Which response by the nurse demonstrates reinforcement of the concepts of cognitive behavioral therapy (CBT)? Select all that apply.

a) You've identified the misconception, now lets work on changing the behavior b) What do you expect to happen if you trust me to do as I promised

The nurse is reviewing the nursing diagnosis identified for a client diagnosed with major depression. Which information should be consistent with the parts of the nursing diagnosis? select all that apply

a) actual or potential problem related to the clients problem b) behavior or symptoms that support the problem c) causative or contributing factors

Which considerations are relevant to the use of psychotropic drugs among the older client population? select all that apply

a) decrease in renal function b) increased risk for dehydration c) decrease in the amount of albumin e) increase in body fat and loss of muscle

Which assessment data would support a diagnosis of binge-eating disorder? (Select all that apply.)

a) history of impulsive behaviors b) demonstrates a low self image c) overweight at a young age

Which statement by the client supports the nurses belief that the individual has the skills to cope with the emotional crisis associated with the death of a spouse?

a) it is so difficult; I can remember what it was like losing my father

Upon which is the value system of sexual offenses focused? (Select all that apply.)

a) power seeking b) self-centeredness

A child is diagnosed with a speech sound disorder. Which assessment findings would the nurse most likely identify as supporting this diagnosis? Select all that apply.

a) producing repetitive syllables b) being between the age of 2 to 7 years c) being male d) increasing symptoms when anxious

A child is exhibiting signs and symptoms of separation anxiety following the parents divorce. Which behaviors should the nurse expect to assess in this child? select all that apply

a) somatic complaints b) refusal to attend school

A 13 year old is diagnosed with Tourettes disorder and parents are learning strategies to help manage the characteristic tics associated with this disorder. Which information should the nurse provide for the child and parents? select all that apply

a) stress tends to trigger the behavior b) Tics tend to decrease during concentrated activities

A nurse is reading a journal article about therapeutic communication. The nurse demonstrates understanding of the information by identifying which statement as reflecting the topic? Select all that apply

a) the focus is on the client c) it requires practice

A child diagnosed with expressive language disorder has a nursing diagnosis of impaired verbal communication. Which nursing intervention would be most appropriate for this child

allowing the child ample time to express themselves

A client has been diagnosed with an anxiety disorder. Which statement would be considered a long term outcome for this client?

d) Demonstrates understanding of need for continued medication compliance by discharge

A client has a history of verbally abusing the clients children. Which question would the nurse most likely use to best determine the clients sense of self-awareness regarding therapy for this problem?

d) Is your relationship with your children important enough to you to make changes in the way you interact with them?

Which of the following terms would be descriptive of a clients attitude?

apathetic

Which statement demonstrates an understanding of the most serious barrier to communication when attempting to establish a therapeutic relationship with a client diagnosed with depression?

b) I cant quite get a clear understanding of how the client expresses sadness"

To foster a sense of safety in a client demonstrating paranoid behavior, which nonverbal technique should the nurse implement?

b) Respecting an extended area of personal space when interacting with the client

A convicted pedophile is going through treatment in an attempt to change the sexual arousal patterns. Which type of therapy should this client be undergoing?

behavioral reconditioning

The nurse is reviewing a mental health assessment on a client diagnosed with schizophrenia. Which term would the nurse identify as describing the client's affect?

blunted

A nurse is documenting subjective data about a client diagnosed with chronic depression. Which statement would reflect the most descriptive and accurate documentation about the client?

c) Client states," I cant remember a time when I wasnt depressed and able to really enjoy my life".

The nurse is working with a client who has made a sexually inappropriate remark. To maintain appropriate professional boundaries while continuing to preserve a therapeutic nurse-patient relationship, the nurse will initially implement which intervention?

c) In a direct manner, explain immediately why the remark was unacceptable and disturbing.

A nurse effectively advocates for a client by demonstrating a positive regard for the client's needs. Select the benefit of this action that is most directly related to the nurse's actions regarding the client's needs.

c) compliance with the treatment

Which statement made by a mental health nurse demonstrates a need for additional education regarding the importance of maintaining professional boundaries?

c) im available to talk with you whenever im here on the unit

What response best teaches the client about the events and outcome expected with electroconvulsive therapy treatment?

d) A controlled seizure occurs that helps to restore a chemical balance in the brain

Which intervention demonstrates the nurses best effort to maintain a milieu where clients are accepted regardless of their mental illness?

d) Nurse makes sure it is possible for every client regardless of their physical or mental limitations to take part in the units holiday program

The nurse is addressing the needs presented by a woman who has just left an abusive spouse. The nurse would initially focus on which area?

d) Working with the client to identify a safe place to live

The nurse is interviewing the history of a 10-year-old child who repeatedly has been abused physically by both parents. As a result, the child behaves aggressively when faced with frustrations or disappointments. Which nursing intervention will have the greatest impact on modifying these behaviors?

d) role modeling coping skills to appropriately manage frustration and disappointment

A client is diagnosed with anxiety and with a history of abuse as an adult is currently engaged in weekly psychotherapy sessions. The client asks the advanced practice nurse APN, What is the goal of my treatment? Which is the nurse practitioners best response?

d) the goal is to reduce the symptoms you are experiencing

A child diagnosed with an elimination disorder. When reviewing the childs history which information would the nurse identify as a predisposing factor?

developmental delays

A nurse is reviewing a psychosocial assessment on a client diagnosed with depression. Which term could be used to described observations of a clients mood during the psychosocial assessment?

euphoric

Anger, even when justified is a rational means to an end

false

Nursing diagnoses and care should not be planned to include religious and cultural practices of the client

false

Nursing interventions are not intended to encourage, maintain, and reestablish a level of mental and physical functioning that promotes the well-being of the client.

false

Subjectivity, or the ability to view facts and events without distortion by personal feelings, prejudices, or judgements, allows the nurse to remain unbiased and open to what clients say about their problems and about themselves.

false

The nurse is not the only member of the mental health team who can continuously evaluate client response to planned care

false

A client states, " I am hungry, will you buy me a car? Can we go to the movie? The nurse documents the clients statements describing them using which terminology

flight of ideas

A client with an eating disorder is found to have altered oral mucous membranes. This assessment finding supports the client's reliance on which classic weight control behavior?

frequent self-induced vomiting

Using which communication technique would indicate a lack of knowledge about barriers to therapeutic communication

giving advice