NUR326 Mental Health

what are expected findings of MDD?

1. depressed mood 2. difficulty or excessive sleeping 3. indecisiveness 4. decreased ability to concentrate 5. suicidal ideation 6. increase or decrease in motor activity 7. inability to feel pleasure (anhedonia) 8. increase or decrease in weight of more than 5% of total body weight over 1 month

Identify nursing interventions that the nurse can use to assist the client who is experiencing a crisis

1. identify the current problem, and direct interventions for resolution 2. take an active, directive role with the client 3. help the client to set realistic, attainable goals 4. provide for client safety 5. initiate hospitalization to protect clients who have suicidal or homicidal thoughts 6. prioritize interventions to address the client's physical needs first 7. use strategies to decrease anxiety 8. develop a therapeutic nurse-client relationship 9. teach relaxation techniques 10. teach coping skills 11. administer prescribed antianxiety/antidepressant meds

what are appropriate ways to communicate with a client with MDD?

1. make time to be with the client even if they don't speak 2. communicate with observations rather than asking direct questions 3. give directions in simple, concrete sentences 4. allow the client sufficient time to verbally respond

Identify the assessment/communication techniques the nurse should use when assessing the older adult client

1. private, quiet space to accommodate for impaired vision/hearing 2. ask what they preferred to be called 3. stand/sit at their level 4. use touch to communicate caring as appropriate 5. include questions relating to: difficulty sleeping, incontinence, falls/other injuries, depression, dizziness, loss of energy 6. include family and significant others as appropriate 7. obtain detailed med history 8. following interview, summarize and ask for feedback from client

A nurse in a mental health facility is caring for an adult client who has bipolar disorder. The client becomes violent and begins throwing objects at other clients. After calling for assistance, what actions should the nurse take next? (Before applying mechanical restraints)

1. tell the client calmly to sit down (verbal intervention is the least restrictive method when dealing with an aggressive patient) 2. provide the client with a decreased-stimulation environment and attempt diversion or redirection (these interventions are less restrictive than seclusion or restraint and the nurse should attempt these interventions prior to more restrictive actions) 3. offer the client a PRN med like diazepam (it can be necessary for the nurse to administer diazepam to calm the client and is considered less restrictive than mechanical restraints) 4. place the client in a monitored seclusion room (it can become necessary to place the client in seclusion if the client persists in the behavior after attempting less restrictive interventions)

Identify what factors the nurse should assess to determine if role and life changes are contributing to the client's depression

1. whether recent role transitions were expected or unexpected 2. client's knowledge and use of positive coping behaviors 3. participation in community resources 4. client's knowledge and use of stress reduction techniques 5. ability to maintain housing or employment

A nurse enters a clients room and finds them on the floor with their knees to their chest, rocking back and forth, and staring aimlessly. When the nurse asks the client a question, the client does not respond. The nurse recognizes these findings are consistent with which level of anxiety? a. severe b. panic c. mild d. moderate

A

A nurse is caring for a newly admitted client who states they are concerned about their privacy and rights while on the psychiatric unit. The nurse should explain to the client that they have which of the following rights? a. the right to refuse treatment b. the right for their information to be shared with their family at any time c. the right for their clinical notes to be shared with anyone at the facility d. the right for providers to solely decide their treatment options

A

A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? a. offering advice b. reflecting c. listening attentively d. giving information

A

A nurse is talking with a client who reports frequently ruminating on things they regret doing in the past. The client states, "I constantly feel like a failure. I've never done anything right". The nurse identifies which of the following techniques as being the best to help this client: a. Cognitive reframing b. Breathing exercises c. Biofeedback d. Priority restructuring

A

A nurse is caring for a client who reports that they are having a hard time completing their ADLs due to feeling anxious. The client also reports feeling tired, difficulty sleeping, and having a poor appetite. The nurse should anticipate they would fall in which end of the mental health continuum? a. The client would fall closer towards the mental illness end or struggling b. The client would fall closer towards the mental health end or thriving c. The client would not clearly fall on the mental health continuum as they do not have a mental illness diagnosis d. The client should be evaluated by the provider before their observance on the mental health continuum is noted, as currently they would fall in the middle

A, the mental health continuum is a range of responses a person displays in response to life events. The ends vary between positive and negative responses, often viewed as mental health versus mental illness. They do not have to be diagnosed with a mental illness to be on the continuum, nor do they have to be evaluated by the provider first.

Match the following findings to the appropriate disorders. a. lanugo and amenorrhea b. Persistent intake restriction. c. Persistent binge eating with compensatory behaviors. d. Russel's sign and enlarged parotid glands. 1. Sign(s) of bulimia nervosa. 2. Sign(s) of severe malnutrition. 3. Sign(s) of purging behaviors. 4. Sign(s) of anorexia nervosa.

A2, B4, C1, D3 Lanugo and amenorrhea are signs of severe malnutrition, common in patients with anorexia nervosa. Russel's sign and enlarged parotid glands are signs of purging behaviors and may be seen in any clients with eating disorders. Persistent binge eating with compensatory behaviors BEST describes a sign of bulimia nervosa. While clients with anorexia nervosa may also have binge-purging behaviors, the persistency and frequency differentiate the diagnosis of anorexia nervosa and bulimia nervosa. Persistent intake restriction BEST describes a sign of anorexia nervosa. While clients with bulimia nervosa may also have restricting behaviors between binging, the persistency and frequency differentiate the diagnosis of anorexia nervosa and bulimia nervosa.

A nurse is discussing the DSM-5 TR with a newly licensed practical nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the DSM-5? a. "I would use the DSM-5 TR to diagnose clients who have mental health disorders." b. "The DSM-5 TR assists in planning nursing interventions for clints who have a mental health disorder." c. "I would use the DSM-5 TR as a guide instructing what specific criteria or questions should be asked for a suspected mental health diagnosis." d. "The DSM-5 TR tells how to treat a patient who has a mental health diagnosis."

B, nurses use the DSM-5 TR diagnostic info to assist with planning, implementing, and evaluating client care. This info can guide nursing interventions for specific needs. A and D are done by the provider, C would lead to biased answers

A nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? a. client's educational and economic background b. lethality of the method and availability of means c. quality of the client's social support d. client's insight into the reasons for the decision

B, priority is to find out: how lethal the method is, how available the method is, and how detailed the plan is

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? a. the client asks the nurse if they will go out to dinner together b. the client accuses the nurse of being controlling just like an ex-partner c. the client reminds the nurse of a friend who died from substance toxicity d. the client becomes angry and threatens to engage in self harm

B, transference is when a client views the nurse as having characteristics of another person A indicates the needs to discuss boundaries, not transference C indicates countertransference D indicates the need for a safety intervention, not transference

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? a. mild b. moderate c. severe d. panic

B. moderate anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious Mild: the clients ability to understand information may actually increase Severe: restlessness, decreased perception, and an inability to take direction Panic: person is completely distracted, unable to function, and may lose touch with reality

A nurse is discussing different factors of the determinants of mental health during a staff meeting. Which of the following factors should the nurse include in the discussion? (SATA) a. receiving paid maternity leave b. unsafe drinking water c. exposure to an adverse childhood event d. a playground in the neighborhood e. national policy addressing cyber-bullying

BCDE, the five categories are life-course, households, community, local services, and country level factors

A charge nurse in conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? a. personal space b. posture c. eye contact d. intonation

D

Identify criteria for admitting a client to a mental health facility

a. clear risk of the client's danger to self/others b. failure to meet expected outcomes of a community-based treatment c. a dangerous decline in the mental health status of a client undergoing long-term treatment d. a client having a medical need in addition to a mental illness

Identify interventions to prevent client self-harm or harm by others.

a. prevent access to sharp/harmful objects b. restrict client access to restricted or locked areas c. monitor visitors d. restrict alcohol and illegal substance access and use e. restrict sexual activity among clients f. deter elopement from facility g. provide rapid de-escalation of disruptive and potentially violent behaviors h. be aware of facility policies and procedures for seclusion/restraints i. provide safe access to recreational areas, therapy, and meeting rooms

Identify responsibilities of the health care team to maintain a therapeutic milieu

a. promote independence for self-care and individual growth b. treat clients as individuals c. allow choices for clients within the daily routine and treatment plan d. apply rules of fair treatment for all clients e. model good social behavior f. work cooperatively as a team to provide care g. maintain boundaries with clients h. maintain a professional appearance and demeanor i. promote safe and satisfying peer interactions among clients j. promote feelings of self-worth and hope for the future

Identify nursing interventions that the nurse can use to assist the client who is experiencing severe anxiety

a. provide an environment that meets the physical and safety needs of the client. remain with the client b. provide a quiet environment with minimal stimulation c. use medications and restraint, but only after less restrictive interventions have failed to decrease anxiety to safer levels d. encourage gross motor activities, such as walking and other forms of exercise e. set limits by using firm, short, and simple statements. repetition may be necessary f. direct the client to acknowledge reality and focus on what is present in the environment

What are manifestations of someone in the crisis level on the mental health continuum?

absenteeism, high anxiety, very poor sleep, weight loss, and very low mood along with exhaustion

Preprocedure nursing interventions for ECT

administer atropine sulfate or glycopyrrolate 30 min prior to ECT establish IV access inform client anesthesia provider will administer short-acting anesthetic via IV bolus inform client the muscle relaxant is administered to paralyze the client's muscles during the seizure activity to decrease risk for injury

intraprocedure nursing interventions for ECT

apply electrodes to scalp for EEG monitoring apply cardiac electrodes for ECG monitoring assist with administration of 100% oxygen during and after ECT until the return of spontaneous respirations monitor vital signs continuously

define behavioral therapy

based on the theory that behavior is learned and has consequences. teach clients ways to decrease anxiety or avoidant behavior and give clients an opportunity to practice techniques

What are environmental determinants of mental health?

basic necessities (such as water), social inequality, pollutants, war, and natural disasters

What is Justice?

fair and equal treatment for all ex: two clients who break the same facility rule are treated equally

What are manifestations of someone at the thriving level on the mental health continuum?

fostering social relationships, performing, positivity, eating well, and calmness

What are manifestations of someone at the struggling level on the mental health continuum?

hopelessness, poor sleep, tiredness, depression, poor appetite, anxiety, and poor performance

define operant conditioning

provides the client with positive rewards for positive behavior

What is Beneficence?

quality of doing good ex: nurse helps a newly admitted client with a psychotic disorder to feel safe in the environment

a nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. which of the following statements should the nurse make? a. tell me about how you are feeling right now b. you should focus on the positive things in your life to decrease your anxiety c. why do you believe you are experiencing this anxiety d. lets discuss the medications your provider is prescribing to decrease your anxiety

A

a nurse is caring for a client who is screaming at staff members and other clients. which of the following is a therapeutic response by the nurse to the client? a. stop screaming, and walk with me outside b. why are you so angry and screaming at everyone c. you will not get your way by screaming d. what was going through your mind when you started screaming?

A

a nurse is caring for an adult client who has injuries resulting from spousal violence. the client does not wish to report the violence to law enforcement authorities. which of the following nursing actions is the highest priority? a. advise the client about the location of safe houses and shelters b. encourage the client to participate in a support group for survivors of abuse c. implement case management to coordinate community and social services d. educate the client about the use of stress management techniques

A

a nurse is planning care for a client who has a body dysmorphic disorder. which of the following actions should the nurse plan to take first? a. assess the client's risk for self harm b. instill hope for positive outcomes c. encourage the client to participate in group therapy sessions d. assist the client to participate in treatment decisions

A

a nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. which of the following actions is the nurse's priority? a. placing the client on one-to-one observation b. assisting the client to perform ADLs c. encouraging the clint to participate in counseling d. teaching the client about med adverse effects

A

A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? a. discussing ways to use new behaviors b. practicing new problem-solving skills c. developing goals d. establishing boundaries

A B happens during the working phase C happens during the orientation phase D happens during the orientation phase

a nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of teaching? a. i will administer prophylactic treatment for sexually transmitted infections, like chlamydia b. i am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence c. i can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder d. i should use narrative documentation when documenting subjective data

A wrong answers: B: always obtain informed consent ******* C: manifestations are similar to PTSD D: document subjective data using client's verbatim statements

a nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90lb. which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? a. life isn't worth living if i gain weight b. don't pretend like you don't know how fat i am c. if i could be skinn i know i'd be popular d. when i look in the mirror, i see myself as obese

A wrong answers: B: this is personalization C: this is overgeneralization D: this is distorted body image

A patient who is at a health clinic reports a sore throat and is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? a. secondary prevention b. tertiary prevention c. modified prevention d. primary prevention

A, Secondary prevention is aimed at early detection of problems, in this case, the identification of depression for early intervention. Primary prevention for mood disorders focuses on stress reduction and societal issues such as reducing poverty and racism. Tertiary prevention aims to reduce disability from a diagnosed condition; for mood disorders, this includes prevention of relapse and protection from harm. Modified prevention is not a recognized level of prevention, although prevention interventions may need to be adapted to meet specific individual situations.

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? a. "The person may have excess energy, talk a lot, feel restless, and spend too much money." b. "The person may experience decreased energy and interest in activities beginning in the winter months." c. "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." d. "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite."

A, Signs that a person is cycling into a manic phase include sleeping and eating less and having increased energy and racing thoughts, increased impulsivity, and increased spending behaviors. Blood pressure may increase related to increased activity, but increased blood pressure and food cravings alone are not indicative of mania. Increased sleep and poor appetite and hygiene are indicative of depression. Decreased energy in winter seasons is indicative of seasonal affective disorder related to decreased sunlight.

Which of the following are appropriate nursing interventions for a client with anorexia nervosa in an acute inpatient setting? (Select all that apply). a. Accompany the client to the bathroom post-prandial (after meals). b. Encourage an exercise routine to increase appetite. c. Celebrate when the client gains at least 2 pounds in one week. d. Allow client to eat whenever they would like while monitoring total intake.

A, The correct nursing intervention is to accompany the client to the bathroom post-prandial (after meals). This is to ensure there are no purging behaviors. Allowing the client to eat whenever they would like could encourage binging behaviors. The best intervention is structured and routine meal and snacks times. Nurses should not celebrate clients gaining weight as this could exacerbate client fears related to weight gain. In most settings for eating disorder treatment, blind weights are taken, meaning clients are not able to know their weight.. Many clients with eating disorders over exercise to control weight. Exercise is not an appropriate part of treatment in an acute setting.

AA nurse is caring for a client who speaks a different language than the nurse. The nurse is looking for resources to assist with providing educational instructions about the client's medication. Which of the following resources should the nurse use? a. US Department of Health and Human Services b. Healthy People 2020 c. Centers for Disease Control and Prevention d. The Mayo Clinic Website

A, US Dep of HHS has a set of culturally and linguistically appropriate services standards to assist in working with people who speak a limited amount of English Healthy People 2020 is an initiative that strives to set national health improvement goals and objectives to assist with these goals. CDC's purpose is to protect Americans from health and safety threats (illness or disease outbreak). The Mayo Clinic website provides educational info for clients on disease and info regarding their medical services

a nurse is teaching a client about stress-reduction techniques. which of the following client statements indicates understanding of the teaching? a. cognitive reframing will help me change my irrational thoughts to something positive b. progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate c. biofeedback causes my body to release endorphins so that i feel less stress and anxiety d. mindfulness allows me to prioritize the stressors that i have in my life so that i have less anxiety

A, cognitive reframing helps the client look at irrational thoughts in a more realistic light and restructure those thoughts in a more positive way wrong answers: B: biofeedback uses a mechanical device to promote voluntary control over autonomic functions C: physical exercise does this D: priority restructuring does this

a nurse is preparing an educational seminar on stress for other nursing staff. which of the following information should the nurse include in the discussion? a. excessive stressors cause the client to experience distress b. the body's initial adaptive response to stress is denial c. absence of stressors results in homeostasis d. negative, rather than positive, stressors produce a biological response

A, distress is the result of excessive or damaging stressors wrong answers: B: denial is a part of the grief process C: individuals need the presence of some stressors to provide interest and purpose in life D: positive and negative stressors produce biological responses in the body

A nurse is explaining what "duty to warn" means to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding? a. "If a client threatens to harm another person, health care providers have a responsibility to inform that person." b. "If a client threatens to harm themselves, there is a responsibility to report that client to their family." c. "If a client threatens to harm themselves, there is a responsibility to tell their medical provider." d. "If a client threatens to harm another person, there is a responsibility to inform the other person's family."

A, duty to warn when there is a treat from a client to another person to cause harm to them

a nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. the nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. which of the following types of treatment is this method an example? a. aversion therapy b. flooding c. biofeedback d. dialectical behavior therapy

A, pairs a maladaptive behavior with an unpleasant stimuli to promote a change in behavior wrong answers: B: planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response C: behavioral therapy to control pain, tension, and anxiety D: cognitive/behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior

Mark rarely goes out with friends and only attends social events when a family member is also present. He often cancels at the last minute and says he is sick. He exhibits behavior typical of which anxiety disorder? a. agoraphobia b. ptsd c. general anxiety disorder d. panic disorder

A, the client experiences an extreme fear of certain places (the outdoors or being on a bridge) where the client feels vulnerable or unsafe Other anxiety disorders: Separation anxiety disorder: excessive fear/anxiety of when separated from someone they are emotionally attached to Specific phobias Social anxiety disorder: excessive fear of social or performance situations Panic disorder: regular panic attacks Generalized Anxiety Disorder: uncontrollable, excessive worry for at least 6 months

A nurse is discussing ethical principles with another nurse. Which of the following should the nurse include as an examples of the principle of nonmaleficence? a. a nurse evaluates the clint's desire for autonomy while considering the personal safety of other clients on the unit b. a nurse encourages the client to determine which therapeutic activity they would like to participate in c. a nurse plans to spend equal amounts of time with each client assigned to their care d. a nurse makes a referral to speech therapy for a client who is experiencing dysphagia

A, the principle of nonmaleficence involves doing no harm. by weighing the risks and benefits of the client's desire for autonomy while considering the safety of the other clients on the unit, the nurse is practicing nonmaleficence B is principle of autonomy C is principle of justice D is principle of beneficence

A charge nurse is discussing mental status examinations with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (SATA) a. to assess cognitive ability, I should ask the client to count backward by sevens b. to assess affect, I should observe the client's facial expression c. to assess language ability, I should instruct the client to write a sentence d. to assess remote memory, I should have the client repeat a list of objects e. to assess the client's abstract thinking, I should ask the client to identify our most recent presidents

ABC D is assessing immediate memory E is assessing cognitive ability

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (SATA) a. educational groups b. medication dispensing programs c. individual counseling programs d. detoxification programs e. family therapy

ABCE Detox programs are provided in a partial hospitalization program

Risk factors for depression include which of the following (Select all that apply). a. Living with chronic or disabling medical conditions b. Co-occurring disorders such as substance use disorder, anxiety, or personality disorders c. Being female d. Having adverse childhood experiences

ABD

a nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. which of the following techniques should the nurse include in the plan of care (SATA) a. priority restructuring b. monitoring thoughts c. diaphragmatic breathing d. journal keeping e. meditation

ABD wrong answers: C: behavioral therapy technique E: behavioral therapy technique

A nurse is facilitating a group discussion about mental health at a local community center. One of the group members states, "My family lost their home and now my child and I are living in a community shelter. It's all been so much to handle. I can't eat or sleep and it's affecting my ability to work." Which of the following factors should the nurse identify as indications this client is at increased risk for a mental health disorder? (SATA) a. dietary intake b. workload c. current living situation d. sleep habits e. parenthood

ACD, The nurse should identify multiple factors that can impact a client's mental health status. Adverse life events such as the loss of a home and living in a community shelter, along with the client's reported physiological effects such as having difficulty eating and sleeping, can increase the risk for the development of a mental health disorder. Although the client reported their ability to work has been negatively impacted, this is a result of the stressors they are currently experiencing rather than a risk factor for mental health disorders. The client reported the child remains with them and is living in the community shelter, but this is not an indication of the client's parenting skills and does not present as a risk factor for mental health disorders.

The nurse is caring for a patient newly diagnosed with major depressive disorder. What typical signs and symptoms would the nurse expect? (SATA) a. appetite changes b. increased fever c. poor eye contact d. slowed speech e. increased white blood cell count

ACD, Typical signs of depression include sleep disturbance; poor eye contact; loss of interest in events; guilt; decreased energy, speech, and concentration; appetite changes; and slowed motor movements. Increased fever and white blood cell count are indicative of infection, not depression.

a nurse is obtaining medical history from a client who has a new diagnosis of anorexia nervosa. which of the following questions should the nurse include in the assessment? (SATA) a. what is your relationship like with your family? b. why do you want to lose weight? c. would you describe your current eating habits? d. at what weight do you believe you will look better? e. can you discuss your feelings about your appearance?

ACE assessment should include family and interpersonal relationships, current eating habits, and their perception of the issue wrong answers: B: "why" sucks D: promotes cognitive distortion

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (SATA) a. my family will be better off if I'm dead b. the stress in my life is too much to handle c. I wish my life was over d. I don't feel like I can ever be happy again e. If I kill myself then my problems will go away

ACE, a statement is an overt comment about suicide if the client directly talks about their perception of an outcome of their death BD are cover comments, where the client identifies a problem but does not directly talk about suicide, there is a need to assess for suicidal ideation

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (SATA) a. conducting a suicide risk screening on all new clients b. creating a support group for family members of clients who completed suicide c. educating high school teens about suicide prevention d. initiating one-on-one observation for a client who has current suicidal ideation e. teaching middle-school educators about warning indicators of suicide

ACE, primary intervention includes screening and community education B is tertiary prevention D is secondary prevention

a nurse is assessing a client who has GAD. which of the following findings should the nurse expect? (SATA) a. excessive worry for 6 months b. impulsive decision making c. delayed reflexes d. restlessness e. sleep disturbance

ADE Why BC are wrong: GAD is characterized by muscle tension and procrastination in decision making

a nurse is planning care for a client following surgical implantation of a VNS device. the nurse should plan to monitor for which of the following adverse effects? (SATA) a. voice changes b. seizure activity c. disorientation d. cough e. neck pain

ADE wrong answers: BC are adverse effects of ECT

As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a. Ask the provider to order labs to identify an underlying cause of depression b. Assess for depression and ask directly about thoughts of suicide. c. Focus on the presenting problems and refer the patient for a mental health evaluation. d. Interview the patient's family to identify their concerns about the patient's behaviors.

B

a nurse is caring for a client who has bipolar disorder. the client states "i am very rich, and i feel i must give my money to you." which of the following responses should the nurse make? a. why do you think you feel the need to give money away b. i am here to provide care and cannot accept this from you c. i can request that you case manager discuss appropriate charity options with you d. you should know that giving away your money is inappropriate

B

a nurse is caring for a client who is speaking in a loud voice with clenched fists. which of the following actions should the nurse take? a. insist that the client stop yelling b. request that other staff members remain close by c. move as close to the client as possible d. walk away from the client

B

a nurse is talked with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but i'm not ready to do that." which of the following recommendations should the nurse make? a. learn to practice mindfulness b. use assertiveness techniques c. exercise regularly d. rely on the support of a close friend

B

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? a. coordinate holistic care with social services b. identify the client's perception of their mental health status c. include the client's family in the interview d. teach the client about their current mental health disorder

B ACD, appropriate if the client wishes but there is another priority

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? a. reaction formation b. denial c. displacement d. sublimation

B Reaction formation is overcompensating or demonstrating the opposite behavior of what is felt. Displacement is shifting feelings related to an object/person/situation to another less threatening object/person/situation. Sublimation is dealing with unacceptable feelings/impulses by unconsciously substituting acceptable forms of expression.

a community health nurse is leading a discussion about rape with a neighborhood task force. which of the following statements by a neighborhood citizen indicates an understanding of the teaching? a. rape is a crime of passion b. acquaintance rape often involves alcohol c. young adults are the typical victims of sexual assault d. the majority of rapists are unknown to the victims

B wrong answers: A: rape is a crime of violence, aggression, anger, and power C: all ages, male or female D: majority of perpetrators are known to the victims

a nurse is preparing a community education seminar about family violence. when discussing types of violence, the nurse should include which of the following? a. refusing to pay bills for a dependent, even when funds are available, is neglect b. intentionally causing someone to fall is an example of physical violence c. striking a sexual partner is an example of sexual violence d. failure to provide a stimulating environment for normal development is emotional abuse

B wrong answers: A: this is economic abuse C: this is physical abuse, sexual abuse is when sexual contact takes place without consent D: this is neglect

A nurse is reviewing the medical records of multiple clients t a community mental health facility. Which of the following events is an example of a client experiencing a maturational crisis? a. rape b. marriage c. severe physical illness d. job loss

B, a maturational crisis is a naturally occurring event during the lifespan A: adventitious crisis, not a part of every day life C: situational crisis D: situational crisis

A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (AST) group? a. a client in an acute care mental health facility who has failed several times while running down the hallway b. a client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia c. a client in a day treatment program who reports increasing anxiety during group therapy d. a client in a weekly grief support group who reports still missing a deceased partner who has been dead for three months

B, an ACT group works with clients who are nonadherent with traditional therapy

A nurse decides to put a client who has psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? a. invasion of privacy b. false imprisonment c. assault d. battery

B, confining a client to a specific area for the convenience of the staff invasion of privacy is the sharing or obtaining of the client's confidential information without the client's consent. assault is making a threat to the client's person. battery involves causing intentional physical harm to clients

A nurse is preparing a poster presentation on the priorities of Health People 2030. Which of the following priority goals should the nurse include? a. the practice of trephination for the treatment of mental illness b. Prevention practices related to cyber-bullying c. increasing institutionalization of clients who have severe mental health disorders d. limit screening of mental illness to those individuals who display manifestations

B, cyber-bullying is a stressor that can result in mental health disorders. By implementing practices targeted at prevention of cyber-bullying, the priority goal of prevention of mental health disorders is met The goals of Healthy People 2030 include prevention and screening along with assessment and treatment of individuals who have mental health disorders; this includes increasing screening for mental health issues during primary care visits

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? a. notify the nurse manager b. tell the nurse to stop discussing the behavior c. provide an in-service program about confidentiality d. complete an incident report

B, invasion of privacy because the information is being shared in a public place other answers are also correct but "b" must be done first

A nurse is planning a presentation regarding mental illness for a local health fair. Which of the following should the nurse include as a characteristic of mental illness? a. resilience following a loss of a job b. difficulty maintaining social relationships c. volunteering at a crisis center d. ending a friendship with an individual who demands participation in dangerous activities

B, mental illnesses are associated with distress/problems functioning in social, work, or family activities

A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? a. even if my anxiety improves, i will need to continue this therapy for 6 weeks b. the therapist will focus on my past relationships during our sessions c. psychoanalysis will help me reduce my anxiety by changing my behaviors d. this therapy will address my conscious feelings about stressful experiences

B, psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder wrong answers: A: this can need many sessions over many months/years C: classic psychoanalysis focuses on resolving the cause of the anxiety rather than changing behaviors D: assesses unconscious thoughts and feelings, not conscious

Which of the following meets criteria for acute admission to a medical/psychiatric unit for an eating disorder? (SATA) a. A client who has had limited success with an individual therapist, has never been in an outpatient program or residential treatment, and reports eating 1100 calories daily. b. A client who has a BMI of 15 kg/m2, a history of alcohol misuse, and reports eating 200 calories daily for the last week. c. A client with a weight loss of 40 pounds in the last 6 months (35% of the client's body weight), an irregular HR of 38 and who reports self-induced vomiting 5+ times daily. d. A client exhibiting signs of hypokalemia: lethargy, leg cramps, and shallow respirations.

BCD, The clients present with subjective and objective data that support a need for both psychiatric treatment and close medical monitoring for significant electrolyte imbalances, cardiac dysthymias and refeeding syndrome

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (SATA) a. "client ate most of their breakfast" b. "client was offered 8oz of water every hr" c. "client shouted obscenities at assistive personnel" d. "client received chlorpromazine 15 mg by mouth at 1000" e. "client acted out after lunch"

BCD, only objective data should be documented "a" would be correct if it stated "client ate 70% of their breakfast"

a nurse is caring for a client who has major depressive disorder. which of the following should the nurse identify as a risk factor for depression? (SATA) a. male sex b. history of chronic bronchitis c. recent death in client's family d. family history of depression e. personal history of panic disorder

BCDE

a nurse is preparing to assess an infant which of the following is an expected finding of shaken baby syndrome? (SATA) a. sunken fontanels b. respiratory distress c. retinal hemorrhage d. altered level of consciousness e. increase in head circumference

BCDE A: bulging fontanels are an expected finding

a nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. which of the following interventions should the nurse include in the plan of care? (SATA) a. provide flexible client behavior expectations b. offer concise explanations c. establish consistent limits d. disregard client concerns e. use a firm approach with communication

BCE

a nurse is discussing acute v prolonged stress with a client. which of the following effects should the nurse identify as an acute stress response? (SATA) a. chronic pain b. depressed immune system c. increased BP d. panic attacks e. unhappiness

BCE AD are related to prolonged or maladaptive stress response

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (SATA) a. reassure the client that everything will be okay b. discuss prior use of coping mechanisms with the client c. ignore the client's anxiety so that they will not be embarrassed d. demonstrate a calm manner while using simple and clear directions e. gather information from the client using closed-ended questions

BD False reassurance and ignoring the problem is bad. Open ended questions are better, they urge the client to express feelings and identify the source of the anxiety

a nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. which of the following is an expected finding? (SATA) a. amenorrhea b. hypokalemia c. yellowing of the skin d. slightly elevated body weight e. presence of lanugo on the face

BD wrong answers are expected findings of anorexia nervosa

a nurse is discussing relapse prevention with a client who has bipolar disorder. which of the following information should the nurse include in the teaching? (SATA) a. use caffeine in moderation to prevent relapse b. difficulty sleeping can indicate a relapse c. begin taking your meds as soon as relapse begins d. participating in psychotherapy can help prevent a relapse e. anhedonia is a clinical manifestation of a depressive relapse

BDE

a nurse is assessing a client in an inpatient mental health unit. which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (SATA) a. lethargy b. defensive responses to questions c. disorientation d. facial grimacing e. agitation

BDE A is likely found in someone with depression C is likely found in someone with a cognitive disorder

A nurse is planning a peer group discussion about the DSM-5. which of the following information is appropriate to include in the discussion? (SATA) a. the DSM-5 includes client education handouts for mental health disorders b. the DSM-5 establishes diagnostic criteria for individual mental health disorders c. the DSM-5 indicates recommended pharmacological treatment for mental health disorders d. the DSM-5assists nurses in planning care for client's who have mental health disorders e. the DSM-5 indicates expected assessment findings of mental health disorders

BDE It does not do A or C

a nurse working in an ED is assessing a preschool age child who reports abdominal pain. which of the following findings should alert the nurse to possible abuse? (SATA) a. abrasions on knees b. round burn marks on forearms c. mismatched clothing d. abdominal rebound tenderness e. areas of ecchymosis on torso

BE

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (SATA) a. lithium carbonate b. paroxetine c. risperidone d. haloperidol e. lorazepam

BE, SSRIs and benzos may be prescribed for someone experiencing a crisis

What are manifestations of someone at the excelling level on the mental health continuum?

Being motivated toward a goal achievement, energetic, positivity, high performance, joyfulness

A charge nurse is presenting on the topic of mental health diagnoses during a unit meeting. The charge nurse should identify that the DSM-5 TR classification is used in conjunction or paired with what other classification system? a. Nursing Intervention Classifications b. Maslow's hierarchy of needs c. International Classification of Disease d. Erikson's Stages of Psychosocial Development

C

A patient newly diagnosed with depression states "I have had other people in my family say that they have depression. Is this an inherited problem?" What is the nurse's best response? a. "Current research is focusing on gut biome as a cause for mood disorders" b. "There are a lot of mood disorders that are caused by many different causes. Inheriting these disorders is not likely" c. "Members of the same family may have the same biological predisposition to experiencing mood disorders." d. "All of your family members raised in the same area have learned to respond to problems in the same way."

C

a charge nurse is discussing the care of a client who has major depressive disorder with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. care during the continuation phase focuses on treating continued manifestations of MDD b. the treatment of MDD during the maintenance phase lasts for 6-12 weeks c. the client is at greatest risk for suicide during the first weeks of an MDD episode d. medication and psychotherapy are most effective during the acute phase of MDD

C

a nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. which of the following is the priority nursing action? a. encourage the client to express feelings out loud b. maintain eye contact with the client c. move the client away from others d. tell the client that the behavior is not acceptable

C

a nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. which of the following findings should the nurse expect? a. wide fluctuations in mood b. report of a minimum of five clinical findings of depression c. presence of manifestations for at least 2 years d. inflated sense of self-esteem

C

a nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. which of the following statements by the newly licensed nurse indicates understanding? a. ECT is the recommended initial treatment for bipolar disorder b. ECT is contraindicated for clients who have suicidal ideation c. ECT is effective for clients who are experiencing severe mania d. ECT is prescribed to prevent relapse of bipolar disorder

C

a nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. the nurse identifies that the repetitive behavior in a client who has OCD is due to which of the following underlying reasons? a. narcissistic behavior b. fear of rejection from staff c. attempt to reduce anxiety d. adverse effect of antidepressant med

C

a nurse is leading a peer group discussion about the indications for ECT. which of the following indications should the nurse include in the discussion? a. borderline personality disorder b. acute withdrawal related to a substance use disorder c. bipolar disorder with rapid cycling d. dysphoric disorder

C ECT is not effective for the other disorders

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? a. a client who has schizophrenia with delusions of grandeur b. a client who has manifestations of depression and attempted suicide a year ago c. a client who has borderline personality disorder and assaulted a homeless man with a metal rod d. a client who has bipolar disorder and paces quickly around the room while talking to themselves

C a client who is a current danger to self or others is a candidate for a temporary emergency admission

a nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder. which of the following statements by the client indicates understanding of the teaching? a. i can expect my problems with PMDD to be worse when I'm menstruating b. i should avoid exercising when I am feeling depressed c. i am aware that my PMDD causes me to have rapid mood swings d. I should increase my caloric intake with a nutritional supplement when my PMDD is active

C problems with PMDD are worst during luteal phase, right before menses

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? a. "I will call your care provider, perhaps you need a different medication." b. "Don't worry, we can try taking it at a different time of day to help it work better." c. "It usually takes a few weeks for you to notice improvement from this medication." d. "Your life is much better now. You will feel better soon."

C, Seeing a response to antidepressants takes 3 to 6 weeks. No change in medication is indicated at this point of treatment, because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that his or her life is better does not acknowledge the patient's feelings.

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow up care? a. receiving daily care from a home health aide b. having a weekly visit from a nurse case worker c. attending a partial hospitalization program d. visiting a community mental health center on a daily basis

C, a partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present ABD will not provide enough supervision for this client

A nurse is working in a neighborhood where the population is culturally diverse. Which of the following actions should the nurse take to ensure the delivery of culturally competent care? a. reflect on their own culture b. read a book about the countries of the residents' ancestry c. talk to the residents of the neighborhood about their culture d. provide care that meets the residents' needs

C, ask don't assume

A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? a. "You and a group of other clients will meet to discuss your treatment plans." b. "Community meetings have specific agenda that is established by staff." c. "You and the other clients will meet with staff to discuss common problems d. "Community meetings are an excellent opportunity to explore your personal mental health issues."

C, community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit A and D happen during individual therapy B community meetings are structured so that they are client led with decisions made by the group as a whole, not the staff

A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make? a. "I feel very sorry for the loneliness you must be experiencing." b. "Suicide is not the appropriate way to cope with loss." c. "Losing someone close to you must be very upsetting." d. "I know how difficult it is to lose a loved one."

C, empathetic response that attempts to understand the client's feelings A is sympathetic rather than empathetic B implies judgement D focuses on nurse's experiences

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? a. keep the client's communications confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife b. keep the client's communication confidential, but watch the client and their roommate closely c. tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others d. report the incident to the health care team, but do not inform the client of the intention to do so

C, information presented is a serious safety issue and nurse shows veracity by telling the client truthfully what must be done

A is nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? a. the nurse discusses the client's weight loss during a health care team meeting b. the nurse examines their own personal feelings about clients who have anorexia nervosa c. the nurse asks the client about personal body image perception d. the nurse presents an educational session about anorexia nervosa to a large group of adolescents

C, interpersonal communication is between nurse and one other person (often the client) A is small-group communication B is intrapersonal communication D is public communication

a nurse is caring for a client who was recently sexually assaulted. the client states "i never should have been out on the street alone at night." which of the following responses should the nurse make? a. your actions had nothing to do with what happened b. you should focus on recovery rather than blaming yourself for what happened c. you believe this wouldn't have happened if you hadn't been out alone? d. why do you feel that you should not have been alone on the street at night?

C, promotes reflection on what client said wrong answers: no one cares about your opinion and "why" questions suck

A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? a. educating clients on health promotion techniques to reduce the risk of depression b. performing screenings for depression at community health programs c. establishing rehabilitations programs to decrease the effects of depression d. providing support groups for clients at risk for depression

C, rehab programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness A is primary prevention B is secondary prevention D is primary prevention

A nurse is providing teaching to a group of newly licensed nurses about stigma. Which of the following client scenarios should the nurse include as an example of self-stigma? a. a client refuses to go to their provider for manifestations of anxiety until they meet with their cultural leader, a shaman b. a client stops taking their medication for anxiety because they do not like how it makes them feel c. a client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know they are on an antidepressant d. a client refuses a follow-up appointment for their anxiety because they are waiting until they can arrange their transportation

C, self-stigma is when an individual has a negative view of internalized shame regarding their mental illness, often due to the public stigma of mental illness. side note: another type of stigma is institutionalized stigma

a nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. which of the following actions should the nurse implement with this form of therapy? a. demonstrate riding in an elevator, and then ask the client to imitate the behavior b. advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator c. gradually expose the client to an elevator while practicing relaxation techniques d. stay with the client in an elevator until the anxiety response diminishes

C, systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli that use relaxation techniques to suppress the anxiety response wrong answers: A: example of modeling B: example of thought stopping C: example of flooding

A nurse is presenting information on mental health services over the last 50 years to a group of newly licensed nurses. in 1946, the National Mental Health Act was signed into law which resulted in which of the following? a. the establishment of the mental health court to determines soundness or fitness to stand trial b. the development of mental health centers throughout community settings c. the creation of the National Institute for Mental Health d. the coverage of mental health services for children and youth

C, the need for psychiatric services has increased over the years, specifically following WWII. The National Institute of Mental Health is a federal agency that researches mental illness and was a pioneers in assisting in the transformation of treatment and understanding of mental illnesses

a nurse is caring for a clie3nt who has bulimia nervosa and has stopped purging behavior. the client tells the nurse about fears of gaining weight. which of the following responses should the nurse make? a. many clients are concerned about their weight. however, the dietitian will ensure that you don't get too many calories in your diet b. instead of worrying about your weight, try to focus on other problems at this time c. i understand you have concerns about your weight, but first, lets talk about your recent accomplishments d. you are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. we know that is important to you

C, this answer acknowledges the clients concern and leads the conversation in a way that improves client self-esteem and self-image

A nurse is planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse visit first? a. a client who received a burn on the arm while using a hot iron at home b. a client who requests a change of antipsychotic medication due to some new adverse effects c. a client who reports hearing a voice saying that life is not worth living anymore d. a client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

C, this client is at greatest risk for self-harm and should be visited first

A nurse is caring for a client who is newly admitted to the acute psychiatric unit for alcohol use disorder. The client reports growing up in an Amish community. Which of the following actions should the nurse take? a. inform the client that the nurse follows Judaism b. provide the client with a Bible c. assess for personal bias related to alcohol use disorder before interacting with the client d. ask the client where they grew up practicing Amish traditions

C, to ensure the nurse does not have any bias in their treatment of the client, the nurse should first understand what their own culture and biases are to not hinder client care A, no one cares B, don't assume D, the nurse should allow the client to provide details of the cultural or religious practices on their own terms

A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (SATA) a. the needs of both participants are met b. an emotional commitment exists between the participants c. it is goal-directed d. behavioral change is encouraged e. a termination date is established

CDE A is wrong because relationship should focus on needs of client B is wrong because the nurse should not get emotionally involved

a nurse is assessing a client immediately following an ECT procedure. which of the following findings should the nurse expect? (SATA) a. hypotension b. paralytic ileus c. memory loss d. polyuria e. confusion

CE wrong answers: A: HTN is expected BD: no

A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? a. offering general leads b. summarizing c. focusing d. restating

D

A nurse is reviewing the medical records of a group of clients. The nurse should identify that which of the following factors places a client at risk for mental illness? a. a family member wit ha diagnosis of diabetes b. a medical diagnosis of diabetes c. a history of using community support services d. a history of abuse

D

A student nurse is preparing a plan to teach clients in a general outpatient mental health program about stress-reduction strategies. Which of the following would NOT be appropriate to include? a. Teaching clients to reframe negative thoughts as positive thoughts. b. Teach the role exercise plays in the release of endorphins that promote relaxation. c. Teaching clients to write down a list of stressors and identify how to destress if those stressors arise. d. Teaching clients with family conflicts to ignore their family members when they are stressed.

D

The nurse is eduating a client about a new generalized anxiety disorder diagnosis. The nurse recognizes which statement requires follow up by the nurse? a. "Anxiety is a normal response to stress. My diagnosis is different because I haven't been able to control my anxiety, and it is impairing my life" b. "When I worry people are mad at me, I should just ignore it until I am less anxious" c. "There are many treatment options for me, including cognitive behavioral therapy and anti-anxiety medications" d. "The doctor diagnosed me with this disorder because I hate the way I look"

D

a nurse is conducting group therapy with a group of clients. which of the following statements made by a client is an example of aggressive communication? a. i wish you would not make me angry b. i feel angry when you leave me c. it makes me angry when you interrupt me d. you'd better listen to me

D

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? a. assist the client with systematic desensitization therapy b. teach the client appropriate coping mechanisms c. assess the client for comorbid health conditions d. monitor the client for adverse effects of medications

D A is a cognitive and behavioral intervention B is a counseling or health teaching intervention C is a health promotion and maintenance intervention

A nurse is talking with the caregiver of a child who has demonestrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassureance about their child's condition, which of the following responses should the nurse make? a. "I thinking your child is getting better. What have you noticed?" b. "I'm sure everything will be okay. I just takes time to heal." c. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" d. "I understand you're concerned. Lets discuss what concerns you specifically."

D remember: no one cares what you think!

a nurse is caring for a client who states "i'm so stressed at work because of my coworker. i am expected to finish others' work because of their laziness!" when discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? a. you really should complete your won work. i don't think its right to expect me to complete your responsibilities b. why do you expect me to finish your work? you must realize that i have my own responsibilities c. it is not fair to expect me to complete your work. if you continue, then i will report your behavior to our supervisor d. when i have to pick up extra work, i feel very overwhelmed. i need to focus on my own responsibilities

D this response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote change

a nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? a. it is common to treat depression with ECT before trying medications b. i can have my depression cured if i receive a series of ECT treatments c. i should receive ECT once a week for 6 weeks d. I will receive a muscle relaxant to protect me from injury during ECT

D wrong answers: A: ECT is indicated for clients who have a major depressive disorder and are not responsive to pharmacological treatment B: does not cure depression but reduces incidence and severity of relapse C: treatment is 2-3/wk for 6-12 treatments

a charge nurse is leading a peer group discussion about family and community violence. which of the following statements by a member of the group indicates an understanding of teaching? a. children older than 5 are at greater risk for abuse b. substance use disorder does not increase risk for violence c. entering an intimate relationship increases the risk for violence d. pregnancy increases the risk for violence from a spouse or partner

D wrong answers: A: children under 4 are at increased risk for abuse B: it does C: vulnerable person are at increased risk when trying to leave a relationship

a charge nurse is discussing TMS with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. TMS is indicated for clients who have schizophrenia spectrum disorders b. i will provide postanesthesia care following TMS c. TMS treatments usually last 5-10 min d. i will schedule the client for TMS treatments 3-5 times a week for the first several weeks

D wrong answers: A: indicated for treatment of major depressive disorders not responsive to pharmacological treatment. ECT is indicated for treatment of schizophrenia spectrum disorders B: client does not receive anesthesia and is alert during the procedure C: 30-40 min

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? a. medication side effects b. antisocial personality c. anxiety d. seasonal affective disorder

D, Decreased exposure to sunlight in winter months can reduce the production of serotonin in the brain, leading to a type of depression termed seasonal affective disorder; this tends to resolve with the longer days and increased exposure to sun of spring and summer. There are not enough data to identify anxiety or signs linked to medication, which also tend to not resolve with seasons. Antisocial traits not only include isolation but also include behaviors of manipulation and lack of remorse in interpersonal relationships.

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? a. a client' verbal threat of suicide is attention-seeking behavior b. interventions are ineffective for clients who really want to commit suicide c. using the term suicide increases the client's risk for a suicide attempt d. a no-suicide contract decreases the client's risk for suicide

D, a contract promotes and maintains trust between the nurse and client (however it should not be used as a replacement for other suicide prevention strategies) ABC: just no

A nurse is reviewing the concept of bias with a newly licensed nurse. Which of the following scenarios should the nurse use to demonstrate biased treatment? a. a client is not permitted to attend the group therapy activity due to wanting to harm another peer in the group b. a client is not permitted to attend the group therapy activity due to having a family therapy session during the same time c. a client is not permitted to attend the group therapy activity due to having thoughts of harming themselves with "anything they can find" d. a client is not permitted to attend the group therapy activity because they practice the Buddhist faith

D, bias is when treatment of a client is verified in the form of stereotyping, prejudice, or discrimination.

a nurse is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. which of the following actions should the nurse include in the client's plan of care? a. allow the client to select preferred meal times b. establish consequences for purging behavior c. provide the client with a high-fat diet at the start of treatment d. implement one-to-one observation during meal times

D, closely monitor the client before and after meals to prevent purging wrong answers: A: use a highly structured milieu B: use a positive approach to client care that uses rewards C: limit high-fat and gas producing foods at the start of treatment

A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? a. i will write down my dreams as soon as i wake up b. i might begin to associate my therapist with important people in my life c. i can learn to express myself in a nonaggressive manner d. i should say the first thing that comes to mind

D, free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind wrong answers: A: example of dream analysis B: example of transference C: example of assertiveness training

a nurse is caring for a client who has bipolar disorder. which of the following is the priority nursing action? a. set consistent limits for expected client behavior b. administer prescribed medications as scheduled c. provide the client with step-by-step instructions during hygiene activities d. monitor the client for escalating behavior

D, most important intervention to promote patient safety

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? a. assign the client to a private room b. document the client's behavior every hour c. allow the client to keep perfume in her room d. ensure that the client swallows medication

D, prevents the client from possibly hoarding meds to overdose A: its better to not give them a private room B: document behavior q15min C: no

a nurse is caring for a client who is experiencing a panic attack. which of the following actions should the nurse take? a. discuss new relaxation techniques b. show the client how to change the behavior c. distract the client with a tv show d. stay with the client and remain quiet

D, promotes safety and reassurance

A nurse is reviewing the chart of a client who has paranoid schizophrenia. The nurse should identify that the DSM-5 TR distinguishes the different types of schizophrenia based on which of the following criteria? a. current medication history b. when the manifestations started c. family history of mental illness d. the client's full history

D, the DSM-5 TR criteria can be broken down based on the client's manifestations obtained during the complete health history

A newly licensed nurse is reviewing the American Nurses Association's core professional values of nursing. Which of the following actions by the nurse demonstrates the value of empowerment? a. the nurse becomes a trainer for the new equipment for other nurses on the unit b. the nurse schedules care around the client's religious practices of daily prayer c. the nurse supports the autonomy of a client who refuses chemotherapy, even though their family wants it d. the nurse provides resources to the client who wants to create a living will before they have surgery

D, the value of empowerment involves the use of decision making to solve problems for the client.

a nurse is assessing a client who experienced sexual assault. which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (SATA) a. genitourinary soreness b. difficulties with low self-esteem c. sleep disturbances d. emotional outbursts e. difficulty making decisions

DE wrong answers: A: this is a somatic reaction B: this is a indication of sustained and maladaptive emotional response C: this is a somatic reaction

What are the levels on the mental health continuum?

Excelling, Thriving, Surviving, Struggling, Crisis

Identify the standardized assessment tool the nurse should use to assess the older adult client's severity of depression

Geriatric Depression Scale

Describe concepts of mental health treatment

Goals of acute mental health treatment: a. prevention of the client harming self/others b. stabilizing mental health crises c. return of clients who are severely ill to some type of community care Interprofessional team members in acute care include: a. nurses b. mental health technicians c. psychologists d. psychiatrists e. other general health care providers f. social workers g. counselors h. occupational and other specialty therapists i. pharmacists

What are nursing interventions that apply to acute mental health care?

Who: the interprofessional team member's primary responsibility is planning and monitoring individualized treatment plans of clinical pathways of care When: plans for discharge to home or to a community facility begin from the time of admission How: nursing roles include overall management of the unit, including client activities and therapeutic milieu Ensuring safe administration and monitoring client meds Implementation of individual client treatment plans, including client teaching Documentation of the nursing process for each client, manage crises as they arise

What is Veracity?

honesty when dealing with a client ex: a client states "you and the other staff member were talking about me weren't you?", the nurse truthfully replies "we were discussing ways to help you relate to the other clients in a more positive way"

What are examples of genetic determinants of mental health?

intellectual disability, gender, race, and age (things you cannot change)

What is Fidelity?

loyalty and faithfulness to the client and one's duty ex: a client asks a nurse to be present when they talk to their guardian for the first time in a year, nurse stays with the client during this interaction

describe the electroconvulsive therapeutic procedure

nonpharmacologic brain stimulation therapy for the treatment of mental health disorders, especially major depressive disorder. Induces seizure activity, which is thought to enhance the effects of neurotransmitters in the brain

What are examples of social determinants of mental health?

physical abuse, job stress, education, job opportunities, social support systems, housing conditions, family dynamics (conditions based on people around you, ATI says these cannot be changed)

What are manifestations of someone at the surviving level on the mental health continuum?

social isolation/withdrawing from society, nervousness, sadness, trouble sleeping, and irritability

What is Autonomy?

the client's right to make their own decisions; client must accept the consequences of those decisions and must respect the decisions of others ex: a nurse helps a client explore all alternatives and arrive at a choice