MH Hesi
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition
Agoraphobia
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Whichinitial intervention is best for the nurse to implement to help the client cope with anxiety related tothis behavior?
Allow time for the ritualistic behavior, then redirect the client to other activities
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?
Are you ever alone when you hear the voices
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care?
Ask one nurse to spend time with the client daily
The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has ahistory of chronic depression. Recently, the client's viral load has begun to increase rather thandecrease despite his adherence to the HIV drug regimen. What should the nurse do first while takingthe client's history upon admission to the hospital?
Ask the client if he takes St. John's Wort routinely
A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit.Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
Decreased thyroid stimulating hormone level
A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues tostate that someone is trying to steal his clothing. Which action should the nurse implement?
Encourage the client to actively participate in assigned activities on the unit
A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
Excessive CNS stimulation will be reduced
Which ego-defense mechanisms are exhibited by a phobic client who refuses to leave her home?
Symbolization
Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IMfluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and familyabout this change in medication regimen?
the effects of alcohol and drug interaction
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?
Accompany her outside for an increasing amount of time each day
At a support meeting of parents of teenaged addicts, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information
Careful monitoring should be provided during withdrawal from the drugs.
On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder?
Psychotic
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
low self-esteem
A 38 year old female client is admitted with a diagnosis of paranoid schizophrenia. When her trade is brought to her, she refuses to eat and tells the nurse "I know you're trying to poisoned me with that food". Which response would be most appropriate for the nurse to make?
"I'll leave your tray here. I'm available if you need anything else"
A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend.After acknowledging the client's fear and anxiety, how should the nurse respond?
"Rape is no limited to strangers and frequently occurs by someone who is known to the victim"
A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
A negative view of self and the future
A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia.During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take?
Assess the content of the hallucinations by asking the client what he is hearing
The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
Black-out after one drink last night on a date
A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention is best to implement?
Cluster care so that brief periods of rest can be scheduled during the day
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)
Fever of 102° F
A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
Flat affect
A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first
His case manager
A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that noone can help me." Which response is best for the nurse to make?
How can I help?
The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Saddam Hussein was my nurse during my last hospitalization. He was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make?
I agree that Saddam Hussein is not a very nice man
A 72-year-old female client is admitted to the psychiatric unit with a medical diagnosis of major depression. Which statement by the client should concern the nurse and require further assessment?
I think my cat is going to die
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is most appropriate for the nurse to make?
I'll leave your tray here. I am available if you need anything else.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
If he might have taken any other drugs
A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate?
Immediately transfer the client to ICU
The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?
Increased self understanding
The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
Ineffective denial related to situational anxiety
The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?
It is a chemical imbalance in the brain that causes disorganized thinking
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction?
Keep your dietary salt intake consistent
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
Let me call and leave a message for your healthcare provider
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?
Let us go back to the activity room and see what is going on in there
The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
Medication management
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?
Moderate levels of anxiety
The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit.Which complaint related to administration of this drug should the nurse expect this client to make?
My mouth feels like cotton
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a grouphome. Which statement is most indicative of the need for careful follow-up after discharge?
Only my belief in God can help me.
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now heknows he is not. Which response is best for the nurse to make?
Others have had similar thoughts when under stress
The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms?
Permit rest periods as needed Speaking slowly and simply Allow the client extra time to complete tasks Observe and encourage food and fluid intake Encourage mild exercise and shorts walks on the unit
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
Projecting her feelings onto the nurse
A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder,manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
Provide a structured environment with little stimuli
A manic depressive client on the psychiatric ward becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take?
Redirect the client's energy by asking him to tidy the recreation room
Which diet selection by a depressed client taking the MAO inhibitor tranylcypromine sulfate (Parnate)indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
Roast beef, baked potato with butter, and iced tea
The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?
Schizophrenia
A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I amliving up to my potential." Which of Maslow's developmental stages is the sales manager attempting toachieve?
Self-Actualization
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?
Stagnation
Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?
Tell me more specifically about your child's accidents.
An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide?
Tell the client that the nurse is there and will help her
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?
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
The nurse observes a schizophrenic female client watching the news on TV. She begins to laugh softlyand says, "Yes, my love, I'll do it." When the nurse questions the client about her comment shestates, "The news commentator is my lover and he speaks to me each evening. Only I can understandwhat he says." What is the best response for the nurse to make?
What do you believe the news commentator said to you?
