RN Mental Health Online Practice 2019 B with NGN

The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

"A support group might be helpful to you during this time." "It is common for people who survived a traumatic event to experience feelings of anxiety." "You should seek help if you have thought of self-harm."

A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who is experiencing delusions of persecution

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

"I will talk about my feelings with a close friend."

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a client's manifestations of depression change."

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?

"It appears as though you would like to open the door."

A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness?

"It is important for our child to have regular dental checkups."

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?

"Let's talk about what it upsetting you."

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?

A 35-year-old client who has major depressive disorder

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Apply restraints: contraindicated Melatonin: anticipated Urinalysis with culture and sensitivity: anticipated Insert indwelling urinary catheter: contraindicated IV fluids: anticipated MRI of the head: nonessential

The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not change, or has declined.

Client follows instructions of the nurse: improved Client attempts to bite nursing staff when offered water: declined Client verbalizes precipitating factors to violent outburst: improved Client is silent and glaring at staff: no change

A nurse is assessing a client who is displaying manifestations of delirium. Which of the following information from the client's medical record are risk factors for delirium? (Select all that apply.)

Client's age Hospital environment Postoperative Fever

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?

Command hallucinations

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Spending adequate time with a client who is verbally abusive.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establish screening programs to identify at-risk clients.

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?

Greater risk of attempting suicide as affect and energy improve

Which of the following findings should the nurse report to the provider immediately? Select the 5 findings that require immediate follow-up.

I&O Sleep/wake cycle Cognitive awareness Temperature Blood pressure

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?

Identify signs of escalation of violence.

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?

Identify the client's trigger foods.

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

Inform the client that this admission is confidential.

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Language delay

The nurse is caring for the client. Which of the following actions should the nurse take? (Select all that apply.)

Maintain continuous observation of the client while in restraints Conduct debriefing with the client and other staff

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?

Nonmaleficence

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.)

Occupational therapy Meal delivery services Physical therapy Home health services

The nurse is caring for the client. Which of the following actions should the nurse take for this client? (Select all that apply.)

Offer the client warm milk at bedtime Maintain a low-stimulation environment for the client Approach the client from the front and speak slowly

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

Older children who are responsible for their younger siblings

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?

Permit the client to perform daily rituals to decrease anxiety.

A nurse is admitting a client who has major depressive disorder and a new prescriptions for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

Select the 6 findings found in the client's medical record that are manifestations of the client's diagnosed personality disorder.

Physical altercations Incidences of self-injury Anxious if left alone Hypersexualization Married multiple times Stealing money from family to cover credit care charges

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli

The nurse is evaluating the client's response to treatments. For each assessment finding, click to specify if the finding is an improvement, no change, or a decline in the client's condition.

Sleep/wake cycle: no change Vitals signs: improvement Daytime orientation: improvement Glucose level: no change I&O: improvement Pain level: improvement Ambulation: decline in condition

Complete the following sentence by using the lists of options.

The client is at risk for developing violent behavior as evidenced by the client's increased agitation.

The nurse is planning care for the client who has delirium and new prescriptions. Complete the following sentence by using the lists of options.

The nurse should first initiate IV fluids followed by administering acetaminophen.