BH Final

A client who had a panic attack on a day before, says to the nurse, "that was a terrible feeling I had yesterday, I'm so afraid to talk about it". The nurse's most therapeutic response is:

"What were you doing yesterday when you first noticed this feeling?"

Which client situation supports a potential diagnosis of a dissociative fugue?

A client from Canada enters the emergency room in New York City without understanding who he/she is and how he/she got there

The client is withdrawing from heroin addictions. What intervention should the nurse implement?

Check vital signs every 8 hours Place the client in a quiet, calm environment Have a consent form signed for HIV testing Provide the client with clean sterile needles

Neuroleptic Malignant Syndrome is a potentially fatal reaction to antipsychotic therapy. what signs and symptoms of this syndrome should the nurse identify?

Diaphoresis Hyper-rigidity Hyperthermia

A client is admitted to the acute medical unit for sever amphetamine intoxication. Which medications should a nurse anticipate will be prescribed to counteract the effects of stimulant intoxication?

Diazepam Propranolol

A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium?

Disorientation to time and place Disorganized thinking Visual or tactile hallucinations Fluctuating levels of consciousness

A nurse is teaching a class about child abuse. What defense mechanism that is most often used by the physically abusive individual should the nurse include?

Displacement

A rape victim tells the ER nurse "I feel so dirty. Help me take a shower before the doctor examines me". The nurse should

Explain that bathing would destry evidene

A nurse is working with clients with a variety of eating disorders, which characteristics unique to bulimia nervosa differentiate this disorder from anorexia nervosa?

Has behaviors and an appearance that appear appropriate

A college student is brought to the mental health clinic by the parents. The diagnosis is a borderline personality disorder. Which factors in the client's history support this diagnosis?

Impulsiveness Lability of mood Self-destructive behavior

A nurse is teaching clients about dietary restrictions when taking an MAOI. What response does the nurse tell them to anticipate if they do not follow restrictions?

Occipital headaches

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do?

Redirect conversation with the nurse to physical symptoms

a widower tells friends "I am going to take my neighbor out for dinner. Its time fro more to be more sociable again". Which phenomenon of bereavement is evident?

Reorganization of behavior directed toward a new object or activity

The nurse observes a coworker acting erratically. The clients assigned to this coworker don't seem to get relief when pain medications are administered. Which action should the nurse take?

Report the nurse's suspicions to the nurse's supervisor or the facility's peer review

Antipsychotic drugs can cause EPS effects. Which responses should the nurse document as indicating pseudoparkinsonim?

Rigidity Tremors Bradykinesia

when reviewing the mediation for a group of clients on a psychiatric unit, the nurse concludes that the pharmacotherapy for anxiety disorders is moving away from benzodiazepines and moving towards

SSRIs

A client comes to a mental health center with severe anxiety evidenced by crying, wringing the hands, and pacing. What should be the nurse's first nursing intervention

Stay physically close to the client

A 20 YO female client who tried LSD as a teen tells the nurse that she has bad dreams that make her want to kill herself. Which is the explanation for this occurrence?

These re flashbacks to a time when the client had a "bad trip"

On admission, a disturbed, unkempt female client refuses to remove her clothing. What should the nurse do to best met the client's needs?

Wait and allow her to undress whenever she is ready to help the client maintain her identity

A nurse is planning care for a depressed client. Which approach is most therapeutic?

allowing the client time to complete activities

A client is admitted to your unit after a suicide attempt by hanging. The nurse's most important aspect of care is to maintain client safety, and so the nurse plan to:

assign a staff member who will remain with the client at all times

A patient has a prescription to receive valproic acid (Depakene) 25mg PO daily. To maximize the client's safety, the nurse schedules administration

at bedtime with a snack (sedative effects)

A female client in the terminal stage of cancer is admitted to the hospital in severe pain. the client refuses the prescribed IM analgesic for pain because it puts her to sleep and she wants to be awake. Despite the client's objections, the nurse administers the pain medication, saying "you know that this will make you more comfortable". The nurse in this situation could be charged with

battery

A cachetic adolescent with a diagnosis of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. the adolescent had been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. Which is a priority when a nurse plans for this clients care?

correcting electrolyte imbalances

a newly admitted client is diagnosed with dissociative identity disorder. Which nursing intervention is priority?

establish an atmosphere of safety and security

what clinical manifestation is the most serious indication of impending assaultive behavior by a client on a mental health unit?

experiences command hallucinations

A client has been receiving imipramine (Tofranil). The nurse notifies the health care provider if which adverse effect to the medication is noted?

increased drowsiness

The nurse caring for a client that has been abusing amphetamines writes a problem of "cardiovascular compromise". Which nursing intervention should be implemented?

monitor the telemetry and vital signs every four hours

A client is discussing a plan to have a lithium level taken on discharge. To obtain an accurate serum level, which discharge teaching should be included?

remind the client to have the lithium serum level drawn after fasting for at least 1 2hours

A client consistently shooses solitaty activities, seems indiffernt to praise and criticism, and has deficits in the ability to form meaningful perosnal relationships. WHich personality disorder diagnosis would the nurse expect to be documented?

schizoid perosnality disorder

A client diagnosed with schizophrenia is given an antipsychotic drug. The nurse considers that of all the extrapyramidal effects associated with this type of medication, the one that requires the discontinuation of the drug is

tardive dyskinesia