COMBINED Exam 2, Mental Health questions

What is the best intervention when a pt is responding to an auditory hallucination?

"Can you tell me what you are hearing?"

A nurse is providing medication teaching for a client who has a new prescription for clozapine. Which of the following statements indicates a need for further teaching?

- "This medication will help prevent seizures."

A cab driver, stuck in traffic, suddenly becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. While being evaluated in the emergency department, the nurse recognizes the signs of severe anxiety. Which of the following would be included as nursing interventions? (Select All that Apply)

- Maintain a calm manner - Remain with the client - Use clear and simple statements

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?

- Using open-ended questions and silence

A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for several months which of the following level should the nurse recognizes the therapeutic lithium level

1.2

foods with tyramine in it

Aged meats or aged cheeses, protein extracts, sour cream, alcohol, anchovies, liver, sausages, overripe figs, bananas, avocados, chocolate, soy sauce, bean curd, natural yogurt, fava beans—tyramine-containing foods—may precipitate hypertensive crisis. Avoid chocolate or caffeine. Herbal: Ginseng, ephedra, ma huang, St. John's wort may cause hypertensive crisis.

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed going out with friends, but now I don't care if they even invite me." Which term best describes this patient's feelings? A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of:

Anhedonia. is a common finding in many types of depression.

The nurse is evaluating the effectiveness of an antipsychotic on negative symptoms of psychosis. Which of the following symptoms would be classified as negative symptoms of psychosis?

Blunted affect Poverty of thought Loss of motivation Inability to experience pleasure or joy

A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new prescription for lorazepam (Ativan). What information should be included? (Select all that apply).

Caution in use of machinery The importance of caffeine restriction Avoidance of alcohol and other sedatives

A nurse is caring for a client with schizophrenia the client spends a great deal of time repeating rhyming syllable such as me See bee tree the nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia

Clang association.

A nurse is assessing a new lead minute client who has generalized anxiety disorder and states I drink alcohol to forget the pain the client is exhibiting a maladaptive responses to each of the following defense mechanisms

Compensation.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse.

Distraction: "Let's go to the dining room for a snack."

Which statement indicates a patient with major depression is most likely outlook on life during the acute phase of the illness?

During an acute phase of major depression, the client may feel worthless and deserve bad things to happen personally.

A nurse is providing teaching to a client who has generalized anxiety disorder in a new prescription for buspirone which of the following statements by the client indicates an understanding of the teaching

I should expect to feel the full effect of my medication in two to four weeks.

Risk for hypertensive crisis: Avoid self-medication. WHY?

OTC preparations containing dextromethorphan, sympathomimetic agents, or antihistamines (e.g., cough, cold, and hay fever remedies, appetite suppressants) can precipitate severe hypertensive reactions if taken during therapy or within 2-3 wk after discontinuation of an MAO inhibitor.

A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardia and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse's first priority?

Panic disorder and a nursing diagnosis of anxiety

A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

Physiologic or physical

I nurse is Kenny for a client who has obsessive-compulsive disorder which of the following action should the nurse take when dealing with the clients ritualistic behaviors

Plan the clients schedule to allow time to perform rituals.

I nurse is caring for a client who has a possessive compulsive disorder the client engages in repeated handwashing daily which of the following should the nurse recognize as the purpose of the clients behavior

Relieving anxiety.

I nurse on an inpatient unit is assessing a client who has claustrophobia the nurse determines the clients condition has improved when he can perform which of the following task

Ride in an elevator.

The nurse is caring for a patient who experiences orthostatic hypotension related to taking chlorpromazine (Thorazine). The nurse should suggest which of the following interventions for managing this side effect?

Rise slowly when getting out of bed.

Two days ago, a client was admitted to the inpatient psychiatric unit with a diagnosis of PTSD and a history of violence. Currently, he continues to have sleep problems, trouble with concentration, and has been feeling increased anger toward another patient who reminds him of a former colleague. The priority nursing diagnosis would be:

Risk for violence

An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

Social skills training.

I nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the day room which of the following action should the nurse take

Speak to the client in a calm voice.

And I just caring for a client who has poster medic stress disorder in which of the following actions by the client indicates the current treatment plan is effective

The client reports techniques she uses to promote sleep.

A nurse is providing teaching to a client who has a new prescription for alprazolam which of the following is the priority information but no should include in the teaching

This medication can affect your ability to drive or handle mechanical equipment.

I nurse and a mental health facility is caring for a client who has generalized anxiety disorder or which of the following statement to the nurse make

Will assist you with making decisions.

A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is:

Within therapeutic limits. The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

You are the nurse responsible for assessing for extrapyramidal side effects in a patient who has been taking chlorpromazine. Which of the following may be side effects for this medication? (Select all that apply.)

acute dystonia. akathisia. dyskinesia. Parkinsonism.

I nurse is assessing a client who is been taking thioridazinefor several days the client reports hand tremors drooling and rigid extremities. Which of the following actions should the nurse take

administer a benzotropine.

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder the laboratory report indicates that the clients current lithium level is one which of the following actions should the nurse take

administer the medication.

A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompaniment when attempting to go out aloneThe client becomes very anxious and must quickly return inside the nurse should identify that the client is exhibiting which of the following disorders

agoraphobia.

A nurse is assessing a client who has a psychotic disorder in a new prescription of haloperidol the client is pacing in the hallway and states I can't seem to set still which of the following extrapyramidal side effects is the client likely experiencing

akathisia.

For depression that is refractory to TCAs. Avoid certain foods such as

cheese, sour cream, wine, beer, figs, anchovies, shrimp, bananas, and chocolate, and avoid drugs (e.g., TCAs).

A nurse is planning a menu for a client who has bipolar disorder and is experiencing acute manic episode which of the following meal should the nurse provide for this client

chicken nuggets crackers with cheese sticks and a cookie.

A school nurse is caring for an adolescent client who has a history of depressive episode one year ago he appears to be drawn from social activities in a school performance is declining which of the following actions should the nurse take first

conduct a suicide risk assessment.

I nurse asked an older dog quiet did you have any visitors yesterday a client responds yes several members of my church choir came to see me the nurse knows that only the clients daughter visited the day before which of the following cognitive impairment is the client demonstrating

confabulation.

Nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety which of the following actions by the nurse implement modeling as a behavioral intervention strategy

demonstrating performance of hand hygiene at schedule times.

A nurse is caring for a client who has a possessive compulsive disorder which of the following actions should the nurse take first

determine the clients Anxiety level.

A nurse is assessing a client who has anxiety disorder and is taking benzo diazepine for which of the following adverse affects of the nurse manager the client

dizziness.

I nurse is providing discharge teaching for a client who has a new prescription for doxepin which of the following adverse affects should the nurse informed the client is associated with this medication

drowsiness.

I nurse in an outpatient mental Health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations which of the following action should the nurse take first

explore what the voices are saying to the client.

A nurse is providing teaching to a client with schizophrenia and it's taking quetiapine the nurse should instruct the client that which of the following blood test should be performed periodically

glucose.

A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal which of the following findings should the nurse expect

headache.

I nurse and the emergency department is assessing a client who has cocaine intoxication which of the following findings should the nurse expect

hypervigilance.

A nurse is caring for a client who has dementia which of the following findings should the nurse expect

impaired judgment

The nurse is assessing a client who has been taking an antipsychotic medication for six years in the provider has started tapering off the dosage The nurse should monitor the client for which of the following manifestations of part of Tardive dyskinesia

in voluntary tongue protrusion.

I nurse is caring for a client who has panic disorder and is experiencing Anxiety at the panic levelwhich of the following actions should the nurse take first

instruct the client to take slow deep breath's.

An emergency room nurse is assessing a client who has an anxiety disorder the client has flashed perspiring profusely and is experiencing palpitations the client begins to scream I am going to die this is it I'm having a heart attack and nursery determine that the clients level of anxiety to be which of the following

panic.

A nurse is performing an admission assessment for a client who has schizophrenia the nurse notices that the clients appearances unkempt and he appears to be actively hallucinating which of the following should be the nurses priority assessment

physical needs.

A nurse in a mental health clinic is assessing a client who has a history of mania which of the following findings indicates that the client is experiencing a relapse

pressured speech.

A nurse is providing teaching to a client who has a new prescription for phenelzine the nurse should teach the client that which of the following over-the-counter medications can cause hypertensive crisis when taken concurrently with phenelzine

pseudoephedrine.

A nurse is caring for a client who has acute delirium which of the following findings should the nurse expect

rapid fluctuation in level of consciousness.

A nurse is reviewing the health history of a young adult client who has depressive disorder which of the following factors should the nurse identify as increasing the clients risk for depression

the client is female

I nurse is providing teaching to a client who has a new prescription for chlorpromazine which of the following statements should the nurse make

this medication as an antipsychotic that controls manifestations of schizophrenia.

A nurse is providing teaching to a client who has a new prescription for diazepam which of the following instruction should the nurse include in the teaching

this medication can be habit-forming.

A nurse is providing discharge teaching for a female client who has an anxiety disorder and a new prescription for lorazepam which of the following instructions should the nurse include in the teaching

this medication must be discontinued by gradual tapering overtime

I nurse is caring for a client who is taking tricyclic antidepressant which of the following adverse effects should the nurse report to the client provider immediately

urinary retention.