Practice Questions for exam 1 (prepu) 240

A psychiatric nurse's colleague has expressed a reluctance to assess a client's risk for suicide, stating, "The last thing I want to do is to plant the thought in the client's head and bring on a suicide attempt." What is the nurse's best response?

"Evidence shows that talking about suicide with clients doesn't cause suicide attempts."

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking?

abstract thinking

During a client interview, the client tells the psychiatric-mental health nurse, "If I told you what I did to my son, you'd never want to speak to me again." What is the nurse's most therapeutic response?

"id very much like to hear about that. And it is okay for you to talk about it with me" ; The nurse should avoid presuming that embarrassment is the motivation behind the client's reluctance.

A psychiatric-mental health nurse is reviewing the medical record of a client diagnosed with schizophrenia and receiving antipsychotic therapy. The nurse determines that the client is at increased risk for tardive dyskinesia based on which factor? Select all that apply.

68 years or older, hx of depression and dementia

Approximately what percentage of suicides in the United States are associated with mental illness or alcohol and substance abuse?

90%

The nursing process is what

A framework for critical thinking about nursing care

A 46-year-old client comes to the community mental health center because the client thinks they might be suffering from depression. When assessing this client, which symptom would the nurse identify as being necessary for the diagnosis of major depressive disorder to be made

A loss of interest or inability to derive pleasure for previously enjoyed activities

The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority?

Administering a mental status exam to assess for psychosis

The nurse is seeing a 43-year-old client whose spouse just died by suicide. Which is a common emotional response that the nurse should anticipate from this client?

Anger toward the loved one who committed suicide

A client who lost a child as a result of an automobile accident by an impaired driver is seen by the nurse in an outpatient mental health clinic. He is exhibiting signs of depression in the context of complicated grief. During the session, the nurse should recognize which of the following as a priority?

Assessing the client for suicidal ideations

The nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action?

Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

The psychiatric-mental health nurse needs to have a basic understanding of information that is unique to individual medications. Which factors that affect pharmacokinetics should the nurse know? Select all that apply.

Contraindications Adverse reactions Indications for use Food and drug interactions

Which type of antidepressants are rarely fatal in overdose?

SSRIS

The client frequently attempts to touch the nurse and the nurse has explained the prohibition against this. Which of the following is the best reason that many psychiatric care units have policies against clients touching one another or staff?

Some clients with mental illness have difficulty understanding the concept of personal boundaries or knowing when touch is or is not appropriate.

A psychiatric-mental health nurse is conducting a risk assessment for a client's safety. Which area would the nurse most likely include when completing this risk assessment? Select all that apply. You Selected:

Suicidal thoughts Violence to others Elopement Falls

The nurse has been contacted by the parent of an adolescent who has posted a note on social media about the desire to kill oneself. Which additional sign is a warning that there is an acute risk of suicide for the client?

The client has been stealing prescription medication from home.

A nurse is meeting a client for the first time. The nurse observes that the client smiles appropriately but is using rambling speech while answering the nurse's questions. Which would most likely be the reason for this behavior?

The client is nervous and insecure.

which foods should the patient avoid when taking tranylcypromine?

Tranylcypromine (Parnate) is a monoamine oxidase inhibitor; clients must avoid foods containing tyramine. Fava beans contain tyramine. Citrus fruit, egg products, and fried foods are not tyramine-containing foods.

A client has been recently diagnosed with schizophrenia and is just beginning treatment with olanzapine. What anticipatory guidance should the nurse provide to the client?

Weight gain is a common side effect of olanzapine. Tardive dyskinesia is associated with long-term use of typical antipsychotics. Atypical antipsychotics are not associated with eye damage and they do not require blood level monitoring.

The client presents with signs and symptoms of anxiety. What conversation initiated by the nurse demonstrates an ineffective therapeutic use of self?

What dresses do you like to wear? Asking the client about the client's preferences on fashion and dressing indicate that the nurse is trying to build a social relationship with client, not engaging in a therapeutic use of self.

When administering and monitoring antidepressant therapy in a client, what would be most appropriate for the nurse to do? Select all that apply.

When administering and monitoring antidepressant therapy in a client, what would be most appropriate for the nurse to do? Select all that apply.

The nurse who is conducting a suicide risk assessment with a client determines the lethality of the plan is as high if which condition is present?

a male client has a firearm

The nurse is talking with the client and demonstrates concern for the way the client is feeling by using verbal affirmations and paraphrasing to show understanding. What communication techniques are being used by the nurse?

active listening

A client is receiving clozapine. For which life-threatening disorder should the nurse be alert when assessing this client?

agranulocytosis

The nurse has been asked to assess a client to determine if the client has a suicide plan. Which question would assist the nurse in assessing this area?

are you thinking about killing yourself right now?

A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action?

assessing the client's blood pressure; Combining phenelzine with beer can precipitate a hypertensive crisis. There is no immediate indication that an emergency code is needed. The client's jugular venous pressure is less likely to be affected and is not a priority for assessment. Performing the MMSE is not a short-term priority.

The nurse has assessed a client's behavior and determines the need to de-escalate the situation. What action should the nurse take initially to calm the client?

calmly call the client by name asking them to come to their room

A client with schizophrenia is erratic in adhering to the antipsychotic regimen. What action best addresses this client's lack of adherence?

changing the route to IM

A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to complete the assessments. What is the most effective way for the nruse to proceed

complete it in several short interactions

The nurse asks a client to list the days of the week in reverse order. The nurse is assessing what?

concentration

A nurse suspects that a client is abusing alcohol while taking prescribed medications. The nurse plans to educate the client on the dangers of mixing medicine with alcohol. Which would be the most effective way for the nurse to approach this subject with the client?

emphasize the importance of truthful information using a nonjudgemental approach

A client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action?

ensuring a plan is in place for a client's community based care

A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer?

escitalopram

The nurse is initiating a therapeutic relationship with a client. Which information would the nurse most likely include when explaining the purpose of this relationship?

facilitating a positive change

A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should ...

help the client to identify and explore other options

A nurse is reviewing the medical record of a young client to determine the client's risk for suicide. Which factor would alert the nurse to an increased risk for this client?

increasd anxiety

Which could be incorporated into the plan of care for a client receiving an antidepressant who is experiencing orthostatic hypotension?

increase hydration

A client is receiving risperidone as part of the treatment plan for schizophrenia. Assessment reveals breast enlargement and evidence of galactorrhea. The nurse interprets this effect as due to which occurrence?

increased prolactin levels

The parent of a child client holds the child close during the initial assessment. Which distance zone is acceptable for people who mutually desire personal contact?

intimate zone

A client has been diagnosed with major depression. The client reports that the client often wakes up during the night and has trouble returning to sleep. The nurse interprets this finding as suggesting what?

middle insomnia

Cognitive psychotherapy is most likely to be appropriate in the care of a client who has been diagnosed with what?

moderate depression

A psychiatric-mental health nurse is assessing the boundaries of a client. Which area would the nurse address when assessing social boundaries? Select all that apply.

norms, customs, roles of behavior

A psychiatric-mental health nurse is providing care to several clients receiving antipsychotic medications. Which client would the nurse identify as being at greatest risk for the development of pseudoparkinsonism?

older adults are at greater risk for developing psedoparkinsomism

A client with a history of schizophrenia states "I am the king of a magical land." When the nurse replies to this by stating who and where the client is, which interview behavior is the nurse exhibiting?

presenting reality

Which is the greatest predictor of a future suicide attempt?

previous suicide attempt

When asking a client to "tell me how having schizophrenia has affected your life" the nurse is assessing for what

reflective insight

While conducting an assessment, the nurse give a client three unrelated words and tells the client to keep those in mind. About 5 minutes later, the nurse asks the client to recite the three words. The nurse is checking which sphere of memory?

short-term

Which of the following is a primary risk factor for suicide?

social isolation

A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight?

sometimes I feel like the world would be better off If i were dead q

A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which of the following actions by the nurse is most likely to help the client be successful in this group?

structuring the activity to facilitate the completion of one specific task

A client who is taking paroxetine reports to the nurse that the client has been nauseated since beginning the medication. Which action is indicated initially?

suggest that the client take the medication with food

Which term describes a nonfatal, self-inflicted destructive act with an explicit or implicit intent to die?

suicide attempt

The client is getting ready to be discharged from the psychiatry unit. A nurse and client has just completed reviewing the client's take-home medications. The nurse is exemplifying which role during this intervention?

teacher

Which situation would most likely indicate a violation of professional boundaries? Select all that apply.

telling people the nurse is the only one who understands the client, spending a lot of time with client, strongly defending a client's behavior during a staff meeting

A client with major depression is scheduled to receive electroconvulsive therapy. The nurse understands that this treatment is typically used in which situation?

the client experiencing catatonia

The nurse has been contacted by the parent of an adolescent who has posted a note on social media about the desire to kill oneself. Which additional sign is a warning that there is an acute risk of suicide for the client?

the client has been stealing prescription medication from home

The nurse is interviewing a client who is newly admitted with a psychiatric disorder and asks questions about the client's medical history. Why is it important for the nurse to know the client's medical history with this assessment? Select all that apply.

the client may have only a physical disorder, the client's physical symptoms can relate to the psychiatric disorder

The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?

the client will independently carry out activities of daily living

A client's frequent night awakenings, early morning rising, and daytime drowsiness have prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care. What information should immediately follow this diagnosis?

the evidence supporting the diagnosis

When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore?

the length and quality of relationships; social assessment also includes identification of the person's social network. The nurse should elicit the information about the size and extent of the network, both relatives and nonrelatives, and the length and quality of the relationships

A client with a history of depression has told the nurse that the client is feeling especially "low" this morning. The nurse has responded by stating, "Try thinking about some of the blessings you have in your life." How should the nurse's statement be best interpreted?

the nurse has inhibited communication by giving advice

A student nurse is helping with discussion with a client. Which of these is an explanation why a student nurse does not use active listening?

the student nurse is thinking ahead for answers

A client with bipolar disorder has responded well to lithium therapy in the inpatient setting and is now being prepared for discharge. What should the nurse teach the client about outpatient lithium therapy?

try to time your visit for the laboroatory in the morning, around 12 hours after your most recent dose

A nurse is reviewing the medical record of a young client to determine the client's risk for suicide. Which factor would alert the nurse to an increased risk for this client?

unemployement

The nurse is caring for a client that is very confused. What intervention should be included with the nurses' non-communication with the client?

use of gentle touch during activities of daily living

An advanced practice nurse has chosen to apply motivational interviewing (MI) in the care of a client who will transition back to the community from inpatient treatment. The nurse should begin to apply this method by:

validating the clients decisions and effect to make change

The nurse states to a client who calls out for help, "I am happy to help you. Please let me know what I can do." Which process is the nurse using with this statement?

validation

A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurses first response

warn the client's neighbor and report to the authorities

A client who is depressed begins to cry and states, "I'm just really sick of feeling this way. Nothing ever seems to go right in my life." Which would be the most appropriate response by the nurse?

you are feeling sad right now. It's a hard time

The nurse is caring for a hospitalized client who is suspicious and guarded. The client tells the nurse that the client does not want anyone to tell the family about the client's condition. What is the nurse's best response when the family calls the hospital unit to inquire about the client's condition?

you are welcome to share any information you think would be helpful