Module 4 Study Questions NUR110 Mental Health

A nurse is assisting a client who has schizophhrenia prepare a relapse plan. which of the following statements should the nurse make?

" you should keep your providers and therapists number with you "

A nurse is speacking to the mother of a 16 years old male adolecent. the mother has concerns about her son. which of the following statements should indicate to the nurse that the adolecent is a high risk for suicide?

"His favorite teacher comitted suicide a few weeks ago" -Adolecents are at risk for copycat suicide if a peer or significant other has comitted suicide.

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

"I can call my therapist when I am hallucinating so that i can talk about my feelings and plans and not hurt anyone"

A nurse is reading the medical record of a client with schizophrenia which says the client echibits depersonalization. which of the following statments from the client confirms that it is experiencing depersonalization?

"My hands and feet are smaller then they used to be"

A nurse is collecting data on a client who is actively hallucinating. Which statement would be therapeutic at this time?

"Sometimes people hear things or voices others cant hear."

A nurse is carying for a client who is asmitted with acute psychosis and is being treated with haloperidol. the nurse should suspect that the client may be experiencing td when the client exhibits

- facial grimacing and eye blinking - toung thrusting and lip smacking

A nurse in a mental health clinic is conducting a staff education session about schizophrenia. which of the following should the nurse identify as negative symptoms?

-Anhedonia -blunt affect

A nurse is carying for a child who has autism spectrum disorder. which of the following should the nurse expect?

-Delayed language development -spins a toy repetitively - ritualistic behavior

Which are positive symptoms of schizophrenia?

-hallucinations - agression -disorganized thinking

A nurse manager is disscussing suicide with nursing staff, which of the follwoing should the nurse manager identify as risk factors for suicide?

-male gender - diagnosis of schizoafective - age grather than 55

a nurse is assesing for the precense of extrapyramidal side effects a client who is taking chlorpromazapin. which of the follwoing findings should the nurse recognixe as EPS?

-muscle spasm of the neck -fidgeting behavior -tremors in the hands

A nurse is providing comunity helath education class about suicide prevention. which of the following should the nurse identify as a risk factor for suicide?

-substance use disorder -age grather than 45 -schizophrenia

A nurse is conducting a group theraphy session for several clients. the group is laughing at a joke and out of the sudden one client with schizophrenia jumps up and runs out of the room sayiing ,"you are making fun of me" the nurse should identify as which of the following characteristics of schizophrenia?

Ideas of reference

word salad

Incoherent mixture of words, phrases, and sentences

a nurse on an acute health facility is carying for a group of clients. which of the following clients is seclusion contraindicated?

A client following a suicide attempt.

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. for which client should the nurse withhold the medication?

A client who has WBC of 2900

A nurse is carying for a client who is extremely suspicious of the nursing staff and other clients. which of the following nursing approaches is appropriate when establishinf a therapeuic relationship with the client?

Adopt a neutral attitude when provioding care

A nurse is carying for a client who has schizophrenia and is experiencing hallucinations. which of the follwoing actions should the nurse take?

Ask the client dirrect questions about the hallucinations

A nurse asks a client to make a safety contract but the client declines. which of the following actions should the nurse identidy as priority?

Assign 1:1 supervision

A nurse is carying for a client who has schizophrenia. the cluent states, "the goverment is forcing thoughts into my brain through satelites=." the nurse should document that the client is experiencing which of the following types of delusion?

Control delusion -A client who is experiencing control delusion belevies that others are trying to control him.

A nurse is carying for an adolecent who has conduct disorder. the client reports that she has receved 5 speeding tickets in the past 6 months. which of the following interventions should the nurse take?

Make a contract with the client not to drive over the speed limit.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?

Use a night light and turn off the television.

A nurse is carying for a hospitialized client who is taking clozaril for the treatment of schizophrenic disorder. which laboratory study prescibed will the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

WBC

neologism

a new word, expression, or usage; the creation or use of new words or senses

A homehealth nurse drives uo to the house of her client, who has schizophrenia with manic episodes. the client is sitting in his porch with a shot gun in his arms. which of the following actions should the nurse take?

keep driving in a path that is going away from the clients house. -removes you from danger

A nurse is developing a plan of care for a newly addmited client with schizophrenia and experiences frequent hallucinations and paranoid delusions. which of the following acts should the nurse plan to take>

limit the number of questions asked during assessments.

A nurse overhears a client who has schizophrenia talking to herself saying 'the flakas are here the flakalas are here" the nurse recoognizes the client use of word flakalas as an example of which of the following alterations in speach?

neologism

A nurse is assisting in planning care for a client who is being admitted to the nursing unit eho has attempted suicide. which of the following priority nursing intervention will the nurse include in the plan of care?

one to one suicide precautions

clang associations

patient uses words that ryme

A charge nurse is disscusing suicide interventions with staff. which of the follwoing should the nurse identidy as an example of secondary intervention

perfomring life-saving measures following a suicide attempt.

A nurse is carying for a agressive major depressive patient experiencing anhedonia and states he saw demons in his room. the nurse recognizes the patient is experiencing>

positive and negative symptoms of schizophrenia

a nurse is carying for a client who has schizophrenia. which of the folowing interventions should be included in the plan of care?

remove medication from sealed packages at the cleints bedside

A nurse in a mental health facility is preparing to interview a client who has schizophrenia. which of the following actions should the nurse take?

sit beside the client rather than facing the client

a nurse is assesing a client with schizophrenia which of the follwoing findings should the nurse expect?

the oatient inevnts words that dont exist `

Schizophrenia main problem is increased dopamine in the clients brain?

true

A nurse is assesing a client who has schizophrenia which has been treated with fluphenazine for several years. which of the folowing should the nurse identify as signs of TD

twisting tounge movements

A nurse is tsking care of a client who has schizophrenia and is taking haloperdiol. the nurse should monitor for which of the folowing adverse effects?

extrapyramidal side effects

a nurse recognize females select more lethal methods to commit suicide

false

A nurse is performing an admission assesment for a client who has schizophrenia. which of the following findings should the nurse identify as negative symptoms?

flat affect

which statment indicates concrete thinking in the client who has schizophrenia

i am aware that each problem has only one solution

which of the following statements indicated that a schizophrenic patient understands the teaching?

i know which of my hallucinations trigger a relapse

A nurse is carying for an adolecent who has recently been diagnosed with schizophrenia,. The client parents are tearful and express feelings of guild. which of the folowing answers should the nurse make

"You say you feeling guilt about your daughters diagnosis, lets talk about whats causing you to feel this way"

A nurse is carying for a client who has schizophrenia and tells the nurse ," they lie to me all the time they are trying to poison my food" which statment should the nurse make?

"You seem to be having frightening thoughs"

A charge nurse overhears another nurse talking with a client with schizophrenia. suddenly the client says "im the devil i am god open the gate for me" which of the following replies by the nurse requires intervention.

"Ther is no gate for me to open"

A nurse in an acute mental health is sitting with a client who has schixophrenia. The client whispers to the nurse, "Im being kept in this jail against my will, please try to take me out" which of the following responses should the nurse make?

"You feel that you dont belong here?"

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says,"im in treatment and i have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?

A nurse is providing teaching for a client who has a new prescription for clozapine. which of the folowing statements indicated the client understanding of the teaching.

"i will rise slowly from laying position to prevent fainth while taking this medication"

A nurse is talking with a cliuent who has schizophrenia. suddenly the client states : im frightened do you hear that? what answer should the nurse do?

"what are the voices telling you?"

a nurse is talking with a client who has schizophrenia, suddenly the client says " im frightened. do you hear that? the voices are telling me to do horrible things" which following response by the nurse is appropriate?

"what are the voices telling you?"

A client commits suicide in an acute mental health facility. which of the following is the priority intevention for staff follwoing the incident?

identify cues in the clients behaviour that might have warned then that he was contemplating suicide.

the nurse observes that the client with schizophrenia consistently does the opposite of what he is told. the nurse recognizes of which of the following alterations in behavior>/

impared impulsive control

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. which of the following statements should the nurse include in the teaching?

increase your fluid and fiber intake to prevent constipation.

A nurse is carying for a clieint following a suicide attempt. which of the following actions shopuld the nurse take?

inspect the client belongings.

the client with schizophrenia stated that the voices are telling her to do bad things. the nurse identifies these finidngs as which of the follwing

comand hallucination

A nurse is carying for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. the nurse should asses the client for which adverse effect?

Dystrithmias

A nurse is carying for a client who has autism spectrum disorder. which of the following findings should the nurse expect?

Echolaloia

alteration in speach ECHOLALIA

constant repeating of what another person is saying

A nurse is working in a suicide prvention discussing suicide intervention with a newly hire nurse, which of the following statements indicates that the newly hire nurse understands when a tertiary intervention is needed?

I should provide counceling for the family following a suicide of the client.

a nurse in the emergency department is assesinga a client who has been taking haloperidol for 3 months. the client has high temperature , high bp, and muscle rigidity. which of the following complications should the nurse expect

NMS

A nurse is assesing a client who is recieving treatment with different anypsychotic medications and who suddenly become ill. Finding includes hyperexia, blood pressure changes and diaphoresis. The nurse should recognize that which of the following effects may be occuring ?

NMS Neuroplectic malignant syndrome

A nurse is making home visit for a 16 year old adolecent who attempetd suicide. which of the following behaviors should alert the nurse that the client still has suicidal intent?

Planning to give his CD collection to his girlfriend

A nurse admits a client with major depressive disorderhearing voices to harm herself and others. the nurse recognizes which pattern the patient is displaying

Positive symptoms

A nurse observers that a client who is psychotic, pacing and agitated and is making aggressive gestures. The clients speech pattern is rapid and the clients affect is belligerent. Based on these observations, the nurse immediate priority of care is?

Provide safety for the client and other clients on the unit

the client with schizophrenia states "the goverment is forcing thoughts into my brain through satekites" which delusion is client experiencing

control

The police arrive at the emergency department with a client who has seriously lacerated both wrists. the initian nursing action is to

examine and treat the wound site

A nurse is reviewing the history of an adolecent client who has conduct disorder. which of the following is an expected finding?

Suspended from school several times in the past year.

A nurse notes documentation in a clients record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristics of which of the following?

The false belief that one is being singled out by others.

A client is being admited to the psychiatric unit after serious suicidal attempt by hanging. The nuses most important aspect of care is to maintain clients safety and plans to

Will remain with him or her at all times