mtfinal

62.After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?

"Are you currently thinking about harming yourself?"

59. a client on a psychiatric unit says " it's a waste of time to be here. i can't talk to you or anyone". which would be an appropriate therapeutic nursing response

"Are you feeling that no one understands?"

68. When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

phase III; the honeymoon phase

31. the client is in a crisis state following an environmental disaster. at the beginning of the initial assessment interview, what should the nurse assist the client to identify

physical safety

90. a nurse asks a client how he is feeling. the client states "i'm feeling a bit nervous today". which response should the nurse make?

please explain what you mean by the word "nervous"

89. a nurse at a college campus mental health counseling center is caring for a student who just failed an examination. the student spends the session berating the instructor and the course. the nurse should recognize this behavior as which defense mechanism

projection

71. a nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. after showing the client to his room, which nursing actions is most therapeutic at this time

remain with the client in his room

3. the nurse is providing care for a patient who was recently diagnosed with major depression. the nurse realizes that which is a priority for care of this patient

safety

74. a nurse is reviewing the medical histories of four clients. which clients may develop extrapyramidal symptoms from medication therapy

schizo

27. a patient has been taking risperidone (risperdal) for a few months and is exhibiting these signs and symptoms upon admission: high fever, muscle rigidity, tachycardia , and a decreased level of consciousness. which adverse effect of anti psychotic do these symptoms best describe

schizophrenia?

14. the nurse is caring for a patient who attempted suicide and is being closely monitored for potential safety hazards. which of the following has the patient lost his rights to?

seclusion (right to privacy)

23. which of the following interventions best demonstrates what a nurse can do to provide structure with a client who has a personality disorder and is making constant demands of staff

set clear rules on behaviors and enforce them consistently

76. a nurse is caring for a group of older adult clients. which manifestations indicates one of the clients is experiencing delirium

sudden onset of symptoms

22. a nurse is assessing a client with schizo, who has been taking risperidone for one year. the nurse notices that the client has grimicing and fine tongue movements. what do these symptoms most likely indicate

tardive dyskinesia

73.a nurse is planning to administer haloperidol (haldol) to a client who has acute psychosis. the nurse should monitor the client for which of the following findings as an adverse effect of the medication

tardive dyskinesia

67. When planning care for a client diagnosed with borderline personality disorder, which self-harm behaviour should a nurse expect the client to exhibit

the use of suicidal gestures to elicit a rescue response from others

36. Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to a 79-year-old widow with mild dementia who lives alone and has a new diagnosis of depression. based on a needs assessment, which of the following problems would the nurse address during her first visit

this must be very difficult for you

95.A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents are mourning in an effective way

throw flowers on the lake at each anniversary date of the accident

85. a nurse is assessing a client who has a new diagnosis of bulimia nervosa. which finding should the nurse expect

tooth erosion

5.you are working with a client who has been admitted with generalized anxiety disorder. the client tells you that she knows she is dying, and no one will tell her. she paces constantly and wrings her hands. which interventions will most likely be included in her plan of care

use a calm approach, encourage to talk about feelings

99. a nurse caring for a client is using active listening skills. which actions should the nurse take

use intermittent eye contact

6.the nurse in a detoxification unit receives a phone call from a person who identifies himself as a newly-admitted patient employer. he asks, "did he fall off the wagon again?. the nurse best response to the called is

we do not give out any information. visitation hours in the hospital are from 9am -6pm daily

100. a nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. which statements by the nurse demonstrates an appropriate response when dealing with manipulative behaviors

you are too only have privileges with positive behavior, period

80.a nurse in an acute care mental health facility is sitting with a client who has schizophrenia. the client whispers to the nurse, "i'm being kept in this prison against my will. please try to get me out. which responses should the nurse make

you feel like you dont belong here?

46. a patient diagnosed with schizo tells the nurse "i eat skiller. tend to end. easte. it blows away. get it?. what therapeutic response should the nurse make

"I am having difficulty understanding what you are saying."

9. which statement made by a patient during an initial assessment interview should serve as the nurses priority focus for the plan of care

"I hear evil voices that tell me to do bad things."

60. a women comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. she states "the beatings have been getting worse, and i'm afraid that next time he might kill me". which is appropriate to reply

"Let's talk about your options so that you don't have to go home."

39. a nurse is providing medication teaching for a client who has a new prescription for clozapine (clozaril). which statement indicated a need for further teaching

"This medication will help prevent seizures."

16. after suffering a myocardial infarction, a 37-year-old executive demands to be discharged from the hospital. he tells the nurse, "just give me my prescriptions and let me get back to work". which is the most appropriate reply

"To ensure improved health, we need to discuss diet, medication, exercise, and lifestyle changes before you are discharged."

58. a depressed client discussing marital problems with the nurse says, "what will i do if my husband asks me for a divorce?" which response by the nurse would be an example of therapeutic communication

"What has happened to make you think that your husband will ask you for a divorce?""

12.a client says to the nurse. "i have nobody anymore. i wish i could just die>" which response from the nurse would be considered non-therapeutic

"You feel like alone; would you like to talk more about the way you feel?"

49. a frightened young woman calls the emergency department and tearfully tells the triage nurse, "i have been raped. please help me!". which nursing question takes priority

ensure safety and well being

54. a client who is delirious yells out to the nurse. "you are an idiot, get me your supervisor". which is the best nursing response in this situation

"You're going through a difficult time. I'll stay with you."

26. a patient tells the nurse her brother just told her that he has inoperable pancreatic cancer. which comment would show empathy by the nurse

"how upsetting this must be for you"

69. Mrs. J has a history of pernicious anemia and visits her physician office by-monthly for vitamin B12 injections order: vitamin B12 0.5mg IM bi-monthly Supply: vitamin B12 1000mcg/ml how many ml of vitamin B12 will Mrs. J be receiving with each dose

0.5 ml

19. a patients family is grieving following his recent death. which action by the nurse offers the most comfort to the family

establishing a therapeutic presence

8. the nurse is caring for a patient who is prescribed haloperidol 4mg orally on admission. an oral suspension of haloridol 2mg/ml is received from the pharmacy. what amount of the oral suspension should the nurse administer to the patient

2 ml

17. which of the following best describes an example of providing primary prevention for domestic violence intervention

it attempts to reduce the harm to the victims in the immediate aftermath of the violence (e.g. separating the victim and the perpetrator; providing immediate crisis counseling for the victim), and to locate, contain, and address the perpetrators.

78. a nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. which response should the nurse make

it sounds like you're having a difficult time

48. a young mother in a severely abusive relationship is admitted to the psychiatric unit after an attempted suicide. the client tells the nurse, "i'm sure things will be fine between us when i get home". what is the most appropriate response for the nurse to make

let's develop a safety plan in case he becomes violent in the future

53. the client admitted to the psychiatric unit diagnosed with schizo is prescribed clozapine (clozaril), an atypical antipsychotic. which laboratory data should the nurse evaluate

Client's white blood cell count.

1.a nurse is working with a patient with a histrionic personality disorder and another patient with a narcissistic personality disorder. for both of these patients, which nursing intervention must be a high priority throughout the inpatient stay

limit setting

72.a nurse is reviewing medication records for several clients who have bipolar disorder. the nurse should recognize that which of the following medication are used to treat clients who have bipolar disorder

lithium carbonate antipsychotics anxiolytics

65. a psychiatrist prescribes a phenelizine for a client. which foods should the nurse teach the client to avoid

lower tyramine--smoked meats, liver, alcohol, dry sausages

55. A client on an in-patient psychiatric unit is experiencing a flashback. Which intervention takes priority?

maintain and reassure the client of his or her safety and security

40. which nursing intervention has highest priority for a patient with bulimia nervosa

medical stabilization

84. a nurse is assessing an adolescent female client who has anorexia nervosa. which findings should the nurse expect

orthostatic hypotension, constipation, amenorrhea (decreased body fat and poor nutrition) tachycardia

20. which of the following potential physical complications are most likely to develop in the alcohol dependent person

patient safety

64. a client is diagnosed with late-stage Alzheimers dementia. to address the client symptoms, which nursing intervention should take priority

patient safety

87. a widow grieving her hisband sudden and unexpected death tells the nurse "i'm not feeling well. yesterday, i saw my husband walk through the door, stop, and smile at me. then he just faded away" which response by the nurse reflects understanding of the clients experience?

71. Counsel the widow that visualizations are a normal part of grieving.

75. a nurseis caring for a client who has major depressive disorder and was prescribed citalopram (celexa) 2 weeks ago with a planned dosage increase 1 week ago. the client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. which actions should the nurse take

explain that antidepressants often take several weeks to be fully effective

92. a nurse on crisis hotline is speaking to a client who says, " I just took an entire bottle of amitriptylline" which of the following responses should the nurse take?

74. "I am glad you called, and I want to send an ambulance to help you."

88.After the death of a spouse, an adult repeatedly says, "I should have made him go to the doctor when he said he didn't feel well." This individual is experiencing:

guilt

52. the client with a major depressive disorder taking a selective serotonin reuptake inhibitor (SSRI) calls the psychiatric clinic and repoprts feeling confused and restless and having an elevated temperature. which action should the nurse take

Instruct client to stop taking SSRI.

4.family members of an alcoholic client asks the nurse to help them intervene. which action is essential for a successful intervention

All family members must describe how addiction affects them.

25. how should a nurse prioritize nursing diagnoses within a clients plan of care

By life-threatening potential. (Consider safety first.)

57. a client diagnosed with bipolar disorder in the manic phase is yelling at another peer in the common area. which nursing intervention takes priority

Calmly redirect and remove the client from the milieu.

41. a client with acute mania has exhausted the staff by noon. the client has joked, manipulated, insulted, and argued all morning. staff members are feeling defensive and fatigued. which is the best action

hold a staff meeting to discuss consistency and limited setting approaches

47. a nurse assesses a patient who reports a 3 week history of depression and crying spells. the patient says "my business is bankrupt, and i was served with divorce papers". which statement by the patient alerts the nurse to a covert suicidal message

i have a plan that will fix everything

43. an 80-year-old female client arrives at the emergency room with her son and daughter-in-law, with whom she lives. she is found to have a broken arm. her son and daughter-in-law seem very agitated with the client. when questioned about how it happened, she drops her head and mumbles that she doesn't really know. after a thorough assessment, the nurse suspect that the client is a victim of elder

Domestic abuse

33. according to maslows hierarchy of needs, which of the following needs should the nurse address first

Either SAFETY or BASIC NEEDS.

44. what is the nurse most appropriate action when a client is seen openly masturbating in the recreation room

Escorting the client out of the room.

21.a nurse is caring for a hospitalized client who is bipolar and will be discharged on lithium. which situation would most likely place the client at risk for developing lithium toxicity

Fasting and extreme exercise

42. a child was abducted and raped. in the emergency department, the child is crying uncontrollably. which personal reaction by the nurse could interfere with childs care

Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

61. if a client demonstrate transference toward a nurse, how should the nurse respond

Help the client to clarify the meaning of the relationship, based on the present situation

86. after her husband died of heart failure, a wife approaches the nurse who cared for her husband. in the hospital hallway the wife shouts angrily, "he'd still be alive if you'd given him your undivided attention!" which response should the nurse implement

I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes."

7.which of the following best describes a nurse who us acting as a role model for advocacy for the mentally ill? the nurse who

I wish you would not insult persons with mental illnesses

97. a nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. which findings indicates the client may be exhibiting maladaptive grieving

Leaves the child's room exactly as it was before loss

63. which interventions should a nurse utilize when caring for an impatient client who expresses anger inappropriately

Maintain calm demeanor, clearly delineate consequences of behavior, set limits on behavior.

29. the nurse is working with a client who is preoccupied with perfection, cannot discard anything and has trouble relaxing. which personality disorders are being described within this example

OCD

79. a nurse is caring for a client who states. "i have got to get out of this hospital! they have found my address and are coming for my family! the nurse responds, "don't worry, no one will harm your family" which types communication breakdown does this response represent?

Offering false reassurance

38. which of the following is a therapeutic communication strategy to use when working with a client who has auditory hallucinations

i understand that the voices seem real to you, but i do not hear any voices

28.which of the following drugs is prescribed for treatment of Alzheimers dementia?

RIVASTIGMINE (EXELON)

32. a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says "thank you for helping mend my broken heart". which is the nurse best response

i'm glad i can help you but i can't accept the gift. my reward is seeing you w/a renewed sense of hope

82. a nurse in the emergency department is assessing a client who has experienced intimate partner abuse. the nurse should monitor the client for which of the following behavioral findings

Self-esteem disturbance

30. which of the following would be appropriate criteria for hospital admission of a person diagnosed with anorexia nervosa

Serum potassium level 2.6 mEq/L. (Electrolyte imbalance, hypothermia, HR < 40, systolic BP > 70).

77. a nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder and is newly admitted to the unit. which actions should the nurse plan to take regarding the clients compulsive behavior

identify situations that precipitate compulsive behavior

11. a patient is involuntarily admitted to a psychotic unit after calling a friend and saying, "i've got a gun and 'i'm going to shoot myself". which rights has the patient lost temporarily

involuntary commitment (civil)

93. a nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. the client comes to the nurse station at 0300 demanding the nurse call the provider immediately. which responses by the nurse is appropriate?

You must be very upset about something

15. which neurotransmitter has been implicated in the development of Alzheimers disease

acetycholine and glutamate

34. the nurse understands that, following a crisis, a client may function better than before the crisis. this happens due to which of the following

acquiring and strengthening coping skills

37. a patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. which intervention is most likely to be acceptable to the patient

allow him supervised access to use food vending machine in the hospital lobby

24. the nurse may choose to include complementary therapies in the care plan for a patient with mental illness. which are examples of complementary therapies

alternative health approaches--yoga, acupuncture, mediation, herb remedies

70. a nurse is caring for a client who has schizo and is experiencing a variety of hallucinations. which hallucinations is the priority for the nurse to address

any hallucination that will cause patient to harm self or others

91. a client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. which is the nurse priority response

are you having thoughts of harming yourself

83. a nurse is caring for a client who has anorexia nervosa and overexercising to avoid gaining weight. which nursing actions should the nurse take

ask the client to agree to talk to the nurse when ever she feels the urge to exercise

51. a client diagnosed with dementia wanders the halls of the locked nursing unit during the day. which would the nurse do first to ensure safe care is implemented

assess the clients gait for steadiness

50. what should be the priority nursing diagnosis for a client experiencing alcohol withdrawal

assess whether or not it is alcohol withdrawal delirium

94.a nurse is caring for a client who has an eating disorder. the nurse is practicing which of the following ethical concepts when the client refuses to drink a nutritional supplement in between meals

autonomy

10. while working with the family members of a dying patient, which interventions should the nurse include in the plan of care?

be present active listening empathetic

66. a highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. which personality disorder should a nurse associate with thi behavior

borderline personality

96.which finding indicates successful completion of an individuals grief and mourning

can tolerate intense emotions reports a decreased preoccupation with loss tends to previous responsibilities takes on additional responsibilities

18. which individual with a mental illness may require emergency or involuntary hospitalization

combative-risk for harm of self or others

45. a client has been receiving oxycodone for moderate pain. the client has returned to the clinic three times for refills of their prescription. what assessment by the nurse, in addition to slurred speech, leads the nurse to suspect opioid intoxication

constricted pupils

81. a nurse is observing a client nonverbal behavior. when evaluating this behavior, the nurse should factor in which of the principles influencing nonverbal communication

cultural influences

35. your patient is very stressed about work, and has started taking yoga classes. which comment would indicate that this physical activity has been successful

decreases blood pressure

2. which of the following co-morbid conditions is associated with anorexia nervosa

depression- always assess for suicide/self harm

98. a nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. which assessment by the nurse would be the initial priority

determining of the client has suicidal thoughts

56. the treatment team is recommending disulfiram (antabuse) for a client who has had multiple admissions for alcohol detoxification. which nursing question directed to the treatment team would protect this client right to informed consent

does this patient have the cognitive ability to be prescribed this medication

13.the nurse is caring for a patient with Alzheimers dementia on the long term care unit. which would be an essential nursing intervention for this patient

encouraging communication and maintaining a calm demeanor