final
A client who is depressed states, "I think my family would be better off without me. They don't need to worry about me anymore." What would be the appropriate first response by the nurse?
"Are you planning to commit suicide?"
The nurse is providing care for a patient demonstrating behaviors associated with moderate levels of anxiety. What question should the nurse ask initially when attempting to help the patient deescalate their anxiety? "Do you know what will help you manage your anxiety?" "Do you need help to manage your anxiety?" "Can you identify what was happening when your anxiety began to increase?" "Are you feeling anxious right now?"
"Can you identify what was happening when your anxiety began to increase?
A husband is upset that his wife's alcohol withdrawal delirium has persisted for a second day. What is the most appropriate initial response by the nurse? "I see that you're worried. We're using medication to ease you wife's discomfort." "This is expected. I suggest that you go home, because there's nothing you can do to help." "Are you afraid that your wife will die? I assure you, very few alcoholics die during the detoxification process." "Are you worried that your wife is uncomfortable while she's going through withdrawal? I'm sure that she's not in pain.
"I see that you're worried. We're using medication to ease you wife's discomfort."
A nurse educator on behavioral health has just presented to staff nurses a training session on how to manage hypertensive crises in patients. Which of the following statements made by a staff nurse after the session indicates the need for further teaching or instruction? Select all that apply.
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A patient is being admitted for bipolar 1 disorder, type 1 which of the following statements made by the patient is an example of grandiose delusion?
??
A patient presents to the emergency room with a sore throat, body aches, and temperature of 100.8F. Upon examination of the list of home medications, which drug would prompt further assessment by the nurse?
Lamotrigine (Lamictal)
Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (haldol) last week. One day, you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, Hr 100, T 104.2F/ what are the priority nursing interventions. Select all that apply
??
The nurse is sitting in the day area with a patient who has been experiencing a major depressive episode. The patient appears flat, makes little eye contact, and nods their head yes or no in response to questions. Which statement by the nurse aligns with what is known about strategies for communicating with a depressed individual?
??
What are the following reasons that nurses lead group? Select all that apply.
??
Which statement made by the patient would the nurse identify as a risk factor for suicide?
??
A client with depression has been taking escitalopram (Lexapro) for the last 3 months and has noticed improvement of symptoms. The nurse asks the client about any side effects they have experienced. What would the nurse expect the client to report?
???
The nurse is caring for a patient with panic disorder in the inpatient unit. What primary characteristics of this disorder does the nurse know the patient likely struggles with?
???
A 23-year-old woman present in the outpatient psychiatric clinic and is diagnosed with bipolar 2 disorders. She is prescribed valproic acid (Depakote). Which statement by the patient indicates the nurse's teaching about the medication has been effective? "I will avoid taking this at bedtime because it may cause insomnia." "I will replace my Depo-Provera shot with an intrauterine device(IUD)." "I will start using condoms in addition to my birth control pills." "I will stop taking my antidepressant now because this is all I need."
"I will start using condoms in addition to my birth control pills."
A confused, hallucinating client says, "My arms are turning into stone." What is the most therapeutic response? "May I examine your arms?" "When did this feeling first start?" "That's a rather unusual sensation." "It can be frightening to feel that way."
"It can be frightening to feel that way."
A patient expresses sadness, stating "being all alone with no one to share my life with." Which response by the nurse demonstrates the experience of a therapeutic relationship? "Loneliness can be a very painful and difficult emotion." "Let's talk and see if you and I have any interests in common." "I use Facebook to find people who share my love of cooking." "Loneliness is managed by getting involved with people."
"Loneliness can be a very painful and difficult emotion."
Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of the following nursing assessments is essential before giving a dose of this medication? Assessing the client's blood pressure Determining when the client last used an opiate Monitoring the client for tremors Completing a thorough physical assessment
Assessing the client's blood pressure
A bipolar patient who has been manic and psychotic for the past two weeks is receiving haloperidol (Haldol) twice daily. The nurse determines that this medication has been effective when the patient makes which statement? "The doctor told me if it wasn't for my disorder I could be where he is." "My appetite seems to be returning again and I'm gaining weight.." "I know the FBI is not trying to recruit me for a secret mission." "I have noticed I am able to concentrate better during activities."
"My appetite seems to be returning again and I'm gaining weight."
client is pacing in the hall when the nurse overhears the client say, "Leave me alone. I am not a member of the secret service." How should the nurse respond? "Do you want to put a puzzle together with me" "Go rest in your room and I will be there soon" "Tell me what you are hearing right now" "The secret service is not here in the hospital"
"Tell me what you are hearing right now."
Clonazepam (Klonopin), has been prescribed for a client. Which statement by the client would indicate to the nurse that education about this medication has been effective? "This medication presents no risk of addiction or dependence. "This medication will quickly relax me, so I can focus on problem solving." "My anxiety will be eliminated if I take this medication as prescribed." "I will probably always need to take this medication for my anxiety."
"This medication will quickly relax me, so I can focus on problem solving."
The nurse is establishing a therapeutic environment with a newly admitted client with a severe mental illness. Which statement best demonstrates empathetic communication? "I feel really bad that you have this disorder." "You appear upset. Do you want to talk about it?" "You appear upset. Why do you feel this way?" "Many people have this disorder. You will feel better in no time."
"You appear upset. Do you want to talk about it?"
Which of the following would the nurse recognize as signs of alcohol withdrawal? Select all that apply.
Diaphoresis, nausea, increased BP, tremors
The nurse is caring for a client who requires an opiate medication for chronic pain associated with a previous injury. The client tells the nurse, "Even though I don't feel like I'm addicted to the medication, I get tremors in my hands if I miss a dose."What is the nurse's best response? - "You may be addicted to the medication, but not necessarily physically dependent." - "You may be physically dependent on the medication, but not necessarily addicted." -"The symptoms you describe are indicative of addiction, whether you feel you are or not." _ "The symptoms you describe relate to your disease state and are not normal."
"You may be physically dependent on the medication, but not necessarily addicted."
Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient is experiencing hallucinations?
"You say that you are hearing voices. What are they telling you?"
James is a 42-year-old patient with schizophrenia. He approached you as you arrive for day shift and anxiously reports, "Last night, demons came into my room and tried to rape me." Which response would be most therapeutic?
"You seem very upset. Can you tell me more about what you experienced."
Citalopram (Celexa) is prescribed for a client with generalized anxiety disorder and depression. What information does the nurse include when teaching the client about this drug? "You can become dependent on this medication so only take it when you need it." "Several weeks may pass before you see a noticeable change in your mood." " Make sure to get your blood checked often so you do not develop liver toxicity." "Drink plenty of water while taking this so you do not become dehydrated."
. "Several weeks may pass before you see a noticeable change in your mood."
A client is brought to the emergency department after a friend notices fresh blood on the client's sleeves. During the body check, the nurse visualizes several open, horizontal slash marks on both of their forearms. Which response is appropriate at this time?
?/
A client with a history of traumatic brain injury is admitted for severe anxiety related to intrusive thoughts about having sexual encounters with animals. Upon review of the client's home medication list, which medication causes the most concern for the nurse and needs brought to the provider's attention?
??
A new patient arrives to the inpatient psychiatric unit for using methamphetamine and making suicidal statements. Which action by the nurse should take priority?
??
What is the priority action for a client who is experiencing a flashback?
:Reassuring and protecting the client until the episode subsides
Which nursing intervention is particularly well-chosen for addressing a population at high risk for developing schizophrenia: A) Screening a group of males between the ages of 15 - 25 for early symptoms. B) Forming a support group for females aged 25 - 35 who are diagnosed with substance use issues. C) Providing a group for patients between the ages of 45 - 55 with information on coping skills that have proven to be effective. D) Educating the parents of a group of developmentally delayed 5 - 6 year olds on the importance of early intervention.
A) Screening a group of males between the ages of 15 - 25 for early symptoms.
Which physical finding will lead the nurse to suspect that the client has bulimia nervosa? Sunken eyes Overweight Lanugo growth on face Abrasions on the knuckles
Abrasions on the knuckles
Citalopram (Celecxa) is prescribed for a client with generalized anxiety disorder and depression. What information does the nurse include when teaching the client about this drug?
Adverse effects: serotonin syndrome
A patient experiencing extrapyramidal side effects is not able to sit still in their chair or stop tapping their feet on the floor. What would the nurse record this observation as in their medical record ?
Akathisia
Eight hours after admission to the ICU following an auto accident, a client begins to exhibit tachycardia, irritability, and tremors. Three hours later the client has a grand mal seizure. Which condition does the nurse suspect? Wernicke encephalopathy Korsakoff syndrome Undetected internal bleeding Alcohol withdrawal syndrome
Alcohol withdrawal syndrome
A home health client with obsessive-compulsive disorder is found in their kitchen staring at the coffee maker and methodically flipping the switch on and off five times every five minutes. How should the home care nurse respond to this behavior? Present reality to the client that the coffee maker is indeed turned off. Encourage the client to accompany them into the other room to talk. Ask the client to stop flipping the switch so the assessment can be completed. Allow the behavior to continue while the nurse conducts the home visit.
Allow the behavior to continue while the nurse conducts the home visit.
A client with obsessive-compulsive disorder washes their hands three times for three minutes, then uses three paper towels to open the door to avoid touching the dirty doorknob. How should the nurse respond initially to this behavior?
Allow the client sufficient time to carry out the ritual.
A client states, "I stopped taking my fluvoxamine (Luvox) yesterday because I never have the desire to have sex with my wife anymore." Which response by the nurse is most therapeutic?
Along the lines of: talking to the physician about changing the medication
The nurse is caring for a client in an outpatient clinic who has selected and obtained lethal measures to follow through the suicide completion. What is the priority action for this client? Arrange for admission to the inpatient behavioral health unit Schedule follow up appointments Encourage coping skills to reduce stress Referral to outpatient
Arrange for admission to the inpatient behavioral health unit
A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action? Tell the client to sit down, calm down, and take a few deep, cleansing breaths. Offer to play a board game with the client or go for a walk together. Offer the client a PRN anti-anxiety medication, such as lorazepam (Ativan). Ask the client to describe what they were doing before these feelings happened.
Ask the client to describe what they were doing before these feelings happened.
Substance abuse is often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her medications. The nurse caring for this patient recognizes that: A. Anxiety may be present. B. Alcohol ingestion is a form of self-medication. C. The patient is lacking a sufficient number of neurotransmitters. D. The patient is using alcohol because she is depressed.
B Alcohol ingestion is a form of self-medication.
To maximize the therapeutic effect, which lifestyle practice should the nurse discourage for a patient who has been recently prescribed an anti anxiety medication? Eating high protein foods. Using acetaminophen without first discussing it with a healthcare provider taking medications after eating dinner or while having a bedtime snack Buying a large coffee with sugar and extra cream each morning on the way to work
Buying a large coffee with sugar and extra cream each morning on the way to work
A 40-year-old patient with bipolar 1 disorder would benefit most from which medication? Carbamazepine (Tegretol) Olanzapine (zyprexa) Paliperidone (invega) Sertraline (zoloft)
Carbamazepine (Tegretol)
A hospitalized, depressed client has been taking nortriptyline (Aventyl) for 1 week. They have become more social and no longer talk about suicide. What should the nurse do in response to the client's behavior? Keep the client under close supervision Arrange for the client to have more visitors Have the client preform a daily-self reflection Observe for client side effects
Keep the client under close supervision
"I like to skate like a freight, don't hate" is an example of what type of speech exhibited by a bipolar patient?
Clang associations Notes: associate words based on rhyming quality and punning
The nurse is reviewing the data below of four clients with psychiatric disorders. Which client would require monitoring of serum sodium levels based on the given data? Client Condition Drug therapy A Panic disorder Escitalopram (lexapro) B Bipolar depression Paroxetine (paxil) C Schizophrenia Asenapine (Saphrris) D Bipolar 1 Disorder Lithium (lithobid)
Client D
The nurse is caring for a client who is making obscene gestures to other staff members and is raising his voice in protest of an ordered test. What is the nurse's first best action? - Determine the patient's level of anxiety. - Determine what basic patient needs are not being met. - Review the patient's chart for previous violent episodes. - Contact the health care provider regarding the patient's actions.
Determine what basic patient needs are not being met
A client with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse make priority for informed decision-making? Empathize with the client about fears regarding ECT. Monitor for any cardiac alterations to prevent possible negative outcomes. Discuss with the client and family expected short-term memory loss. Inform the client that injury related to induced seizure commonly occurs.
Discuss with the client and family expected short-term memory loss.
A new patient arrives to the inpatient psychiatric unit after using methamphetamine and making suicidal statements. Which action by the nurse should take priority? Obtain the patient's vital signs and perform a height and weight on them. Have the patient sign a consent for voluntary admission and release of information Get the patient something to eat and drink prior to starting the admission interview. Examine the patient's body for any weapons, contraband, and pre-existing injuries.
Examine the patient's body for any weapons, contraband, and pre-existing injuries.
The nurse is caring for a client with bipolar 1 who takes lithium (Eskalith). A lab draw for lithium level reveals a serum value of 0.3 mmol/L. What behavior would the nurse expect to see in the client?
Flight of ideas, grandiose
During an inpatient assessment, the nurse determines the patient is demonstrating symptoms of psychosis. What did the patient say that led the nurse to this conclusion? Select all that apply
Hallucinations Secret information
A patient receiving lurasidone (Latuda) for schizophrenia and tells the nurse they have not had a bowel movement for two days. What is the best initial action by the nurse? Contact the physician for an order for a fleets enemea. Contact the physician for an order for an abdominal x-ray. Have the patient drink prune juice and additional fluids. Hold the medication until the patient has a bowel movement.
Have the patient drink prune juice and additional fluids.
A patient is receiving 3 mg of risperidone (risperdal) daily as part of their treatment for schizophrenia. During the morning assessment, the nurse notes that the patient has developed tremors and a temperature of 104 degrees. What should the nurse do next? Administer the morning dose of risperdal and contact the physician Administer the morning dose of risperdal with an antipyretic Hold the morning dose of risperdal and contact the physician Hold the morning dose of risperdal and recheck the temperature in 1 hour
Hold the morning dose of risperdal and contact the physician
Which chronic medical condition would need to be investigated before a diagnosis of major depressive disorder was made? Hypothyroidism Asthma Chron's Migraine headaches
Hypothyroidism
The wife of a client who is taking doxepin (Sinequan) calls the nurse and reports that her husband has become more hopeless and disconnected with life. What is the nurse's best response?
I think this one is about going in to be seen by the physician
A client with a history of alcoholism is found to have Wernicke encephalopathy. What does the nurse anticipate will be prescribed?
IM injections of thiamine
A client with a history of traumatic brain injury and epilepsy is admitted for severe anxiety and depression related to intrusive thoughts about wanting to touch young children. Upon review of the client's home medication list, which medication causes the nurse the most concern and needs brought to the provider's attention? trazodone (Desyrel) escitalopram (Lexapro) duloxetine (Cymbalta) bupropion (Wellbutrin)
Ibupropion (Wellbutrin)
The nurse is caring for a new patient admitted yesterday mornign with suicidal ideation and a plan to hang themselves. The patient is complaining of chronic sleep disturbances. Which medication might the provider order to be taken at bedtime because of its dual purpose?
Medication noradrenergic and specific serotonergic antidepressant (NaSSA) Mirtazapine (remeron)
A primary health care provider prescribed divalproex (depakote) to a client with bipolar 1 disorder. The nurse would expect to see improvement in mood if a lab draw for that depakote level was which value?
Normal: 50-125 ug/mL; toxic level is greater than 150 ug/mL
A client is receiving imipramine (Tofranil) for depression. Which adverse effect specific to this drug class requires further assessment?
Notes to consider: cardiotoxicity- arrhythmias, homicidal ideation Anticholinergic effects- hypotension, dry mouth, constipation, urinary hesitancy And retention
Which side effects of quetiapine (seroquel) would the nurse include in the discharge instructions that are important for the client to monitor at home?
Nurse Central Side Effects Increased BP (children), palpitations, peripheral edema, postural hypotension Acute generalized exanthematous pustulosis, drug reaction with eosinophilia and systemic symptoms (DRESS), stevens-johnson syndrome, sweating GI obstruction, Pancreatitis, anorexia, constipation, dry mouth, dyspepsia Agranulocytosis, decreased hemoglobin, leukopenia, neutropenia Neuroleptic malignant syndrome, seizures, dizziness, cognitive impairment, extrapyramidal symptoms, sedation, tardive dyskinesia
Which of the following should help guide a nurse's fear about "saying the wrong thing" to a patient? -Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation. - The patient is more interested in talking to you than listening to what you have to say and so is not likely to be offended. - Considering the patient's history, there is little chance that the comment will do any actual harm. - Most people with a mentally illness have by necessity developed a high tolerance of forgiveness.
Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
The client tells the nurse that she takes a drink every morning to calm her nerves and stop her tremors. The nurse realizes that the client is at risk for An anxiety disorder A neurologic disorder Physical dependence Psychological addiction
Physical dependence
A 26-year-old patient is brought to the ED by police after jumping off the roofs of several stores with a parachute. During the crisis assessment, the patient talks excessively loud and fast saying "aliens with googly eyes putting thoughts into my head like a fish without water I used to go on the late with my dad until the school I went to asked me to come teach the kids all about the wonder and glory of Jesus and the saucy soup he fed to the four horsemen of the apocalypse." What does the crisis nurse detereine will be a priority nursing response for this patient during the first few days of this hospital stay? - Limit his interaction with other patients - Provide a variety of snacks and meals during his stay on the unit - Prepare a private room for him that can be locked for seclusion on the unit -Keeping the patient's information confidential from all outside callers
Prepare a private room for him that can be locked for seclusion on the unit.
Based on Maslow's hierarchy of needs, physiological needs for a restrained patient include.....Select all that apply. Private toileting, oral hydration Checking the tightness of the restraints Therapeutic communication Maintaining a patent airway
Private toileting, oral hydration Checking the tightness of the restraints Maintaining a patent airway
A nurse detects that a client is experiencing severe-level anxiety. Which nursing intervention should be implemented first?
Provide calm, brief, directive communication.
A client calls the nurse and reports feeling anxious. What is the appropriate initial response? Sit and talk with the client about the feelings. Ask the unlicensed assistive personnel to check on the client. Administer the prescribed as-needed antianxiety medication. Call the client's health care provider to report the client's anxiety.
Sit and talk with the client about the feelings.
A client has been undergoing lithium (Lithobid) therapy since bipolar disorder was diagnosed. The client teached back the following instructions to the nurse regarding pharmacological management of his mental illness. In light of the client's statements, what will the nurse do? Client statement: Drink 2-3L of water everyday Eat a low-sodium diet Have blood drawn prior to each follow up appointment to include lithium level, blood urea nitrogen (BUN) and thyroid stimulating hormone (TSH) Feel confident the client understands the instructions Remind that the diagnostic testing will also include an electrocardiogram (ECG) Provide correct instructions regarding sodium consumption Re-educate, because the client has incorrectly stated most of the instructions
Provide correct instructions regarding sodium consumption
After taking aripiprazole (abilify) for one month, a client reports, "I feel stiff and my hands shake now." The picture below illustrates the client's posture observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude the client has developed?
Pseudo parkinsonism
A client who chronically abuses alcohol has been placed on disulfiram (Antabuse). What important information about this medication will the nurse include in the discharge instructions?
Read products labels carefully to avoid all products containing alcohol.
A client with a family history of diabetes is concerned about the effects of psychiatric medication. Which medication is most likely to cause problems with glucose regulation?
Risperidone (Risperdal)
The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient. Select all that apply
Shaky hands that make holding a cup difficult An upset stomach for no apparent reason
A patient with schizoaffective disorder is taking clozaril (Clozapine). Which laboratory finding would require immediate intervention by the nurse?
WBC count due to potentially fatal side effect of granulocytosis
Which of the following statements indicates that the nurse understands the stages of alcohol withdrawal? Select all that apply.
Stage 1: anxiety, insomnia, nausea and abdominal pain all starting 8 hours after last drink Stage 2: high blood pressure, increased temperature, unusual heart rate + confusion all starting after 24-62 hours after last drink Stage 3: hallucinations, fever, seizures, and agitation starting 72 hours after last drink Symptoms tend to decrease after 5-7 days
the nurse knows which statement is true about stress?
Stress is the wear and tear that life causes on the body
For what reason would a patient with bipolar 2 disorder most likely be admitted to an inpatient psychiatric unit?
Suicidal ideation
What behavior is consistent with therapeutic communication? - Offering your opinion when asked in order to convey support - Summarizing the essence of the patient's comments in your own words. - Interrupting periods of silence before they become awkward for the patient. - Telling the patient he did well when you approve of his statements or actions.
Summarizing the essence of the patient's comments in your own words.
Which behaviors would the nurse expect to observe in a patient experiencing an acute manic episode. Select all that apply.
Switching quickly from one activity to the next
Confidentiality means respecting the client's right to keep his or her information private. When can the nurse share information about the client? Select all that apply The client threatens to harm a family member Sharing the information is in the client's best interest The client gives written permission The client legal guardian ask for information The client is discharged to the parents care The client admits to domestic abuse
The client threatens to harm a family member The client gives written permission The client legal guardian ask for information
Which of the following statements would indicate that teaching about naltrexone (Re Via) has been effective?
This medication will block the effects of any opioid substance I take
Which statement by the client would indicate to the nurse that education about clonazepam (Klonopin) has been effective?
This medication will quickly relax me, so i can focus on problem-solving"
Which of the following is true about benzodiazepines such as diazepam (Valium) and lorazepam (Ativan)?
Typically the #1 choice benzo Acute management of violent behavior Rapid onset of calming and sedating
The patient has been receiving Olanzapine (Zyprexa) for chronic, recurrent psychosis. The nurse assesses that the patient has developed tardive dyskinesia. What findings support this conclusion? Inability to rest or relax, and restlessness Severe muscle spasms of the extremities Tremor, muscle rigidity, and shuffling gait Unusual facial movements and tongue thrusting
Unusual facial movements and tongue thrusting
The serum lithium level of a client admitted during a manic episode is 2.7 mEq/L. What does the nurse expect to find when assessing this client? Decrease in manic behaviors and symptoms Elevation in mood and increased agitation Nausea, thirst, and fine hand tremors Vomiting, confusion, and decreased coordination
Vomiting, confusion, and decreased coordination
A patient with schizophrenia is taking clozaril (Clozapine). Which laboratory finding would require immediate attention by the nurse? WBC 3,000 TSH 1.8 Sodium 139 Fasting glucose 78
WBC 3,000
What question by the nurse leader is helpful in managing a monopolizing member of a group? "You seem angry. Is there something you want to discuss with the group?" "Would it be helpful if you had time to think about the question?" "Would you tell us about experiences that have frightened you?" "Who else would like to share feelings about this issue?"
Who else would like to share feelings about this issue?
A client with depression was prescribed fluoxetine (Prozac). After two days, the client arrives at the hospital and reports restlessness, confusion, and muscle spasms. Upon assessment, the nurse finds an elevated body temperature. Which intervention by the healthcare provider would be the first to occur? Withdrawing the drug Administering isocarboxazid Reducing the dose of the drug Informing the client that these are expected side effects
Withdrawing the drug
An older adult living in a long-term care facility has been receiving 600 mg of lithium twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, slurred speech, the muscle weakness. What is the appropriate nursing intervention? Withhold the next dose of lithium and obtain an order to draw blood to test for toxicity. Suggest to the provider they replace the lithium with an anticonvulsant that will control the mania. Obtain an order for the antidote to lithium and prepare to administer it immediately. Assess the client for coarse hand tremors and, if not present, give the daily dose of lithium.
Withhold the next dose of lithium and obtain and order to draw blood to test for toxicity.
A healthcare provider prescribed clozapine (clozaril) to a client with schizophrenia. What parameters should be assessed before initiating the drug? Select all that apply Absolute neutrophil count Body mass index Serum albumin levels Urine specific gravity White blood cell count
absolute neutrophil count White blood cell count
A patient comes to the emergency department and tells the nurse, "I am going to get clean. I haven't had any drugs or any alcohol for 2 days." The nurse plans care based on the knowledge that withdrawal from which substance can be life threatening? Heroin Alcohol Cocaine Marijuana
alcohol
A client has just been admitted with a diagnosis of schizophrenia, paranoid type. Which is an example of a negative symptom of schizophrenia?
anhedonia
Therapeutic communication is the foundation of a patient-centered interview. Which of the following techniques is not considered therapeutic? Restating Encouraging description of perception Summarizing Asking "why" questions
asking "why" questions
A client who has a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time the client is extremely anxious. What is the priority nursing action?
assigning a staff member to supervise the client
the nurse is providing care to a client taking fluphenazine (Prolixin) for chronic schizophrenia. Which drug does the nurse anticipate will be prescribed for the client for routine use to manage neuromuscular side effects of treatment?
benztropine (cogentin) // ativan
A few hours after the nurse administers the morning dose of paroxetine (Paxil), the patient becomes hostile, confused, shivering, and screaming that he is going to die. The patient's vital signs are as follows: Blood pressure: 158/92 Pulse: 118 SpO2: 99% Temperature: 102.6 F The nurse prepares to call the psychiatrist to report this change in condition. What pharmacological orders might the nurse review? Select all that appl
cyproheptadine (Periactin) dantrolene (Dantrium) lorazepam (Ativan)
Which nursing action(s) are appropriate when providing care to a client who is in 4-point restraints? Select all that apply.
checking tightness of restraints, therapeutic communication, private toileting, oral hydration
A client brings himself to the emergency room in a state of panic because he is currently taking isocarboxazid (Marplan) and attended a cookout a few hours ago when he consumed a large amount of beer and alcohol. What symptoms will the nurse monitor the client for during the remainder of the shift. Select all that apply.
chest pain, hypertension, severe headache
which medication would the nurse be hesitant to call in a prescription for if they knew the patient has a history of repeated attempts of suicide by overdose? clomipramine (Anafranil)- tricycling cardiotoxic a lot of side effects hydroxyzine (Atarax) fluoxetine (Prozac) mitrazapine (Remeron)
clomipramine (Anafranil)- tricycling cardiotoxic a lot of side effects
Which medication does the nurse anticipate will be prescribed to a patient to prevent life-threatening symptoms of alcohol withdrawal? prazosin (Minipress) methadone (Dolophine) diazepam (Valium) clonidine (Catapres)
diazepam (Valium)
Which medication does the nurse anticipate will be prescribed to a patient to prevent life-threatening symptoms of alcohol withdrawal.
diazepam (valium) Prevent seizures
A client has been receiving oxycodone with acetaminophen (Percocet) for moderate pain associated with a serious back injury sustained in a motor vehicle accident. The client has returned three times in the last month for refills of the prescription. Which assessment finding, in addition to slurred speech, leads the nurse to suspect opioid intoxication?
dilated pupils
A sexual assault victum on the behavioral health unit is staring blankly at the wall and not responding to their name or other verbal cues. What action by the nursing assistant warrants further education?
do not touch the client
Client "I had an accident" Nurse: "Tell me about your accident." This is an example of which therapeutic communication technique? Making observations Offering self General lead Reflection
general lead
The nurse has just completed an admission interview and physical assessment. Which findings would be consistent with a diagnosis of borderline personality disorder? Select all that apply. history of mood swings fine scarring noted on both wrists poor personal hygiene habits report a suicide attempt 6 months ago currently prescribed an antianxiety medicine
history of mood swings fine scarring noted on both wrists report a suicide attempt 6 months ago currently prescribed an antianxiety medicine
A nurse is caring for a client who is diagnosed with bipolar 1 disorder. Which assessment finding supports the diagnosis?
impulsivity, labile mood, pressured speech
The nurse is planning care for a client who is addressed to heroin who will begin methadone treatment. Which is the goal of this treatment that the nurse will include in the plan for caer for this client?
it will decrease painful symptoms of withdrawal, blocks euphoric and sedative effect of opiates so no pleasure is felt
A patient presents to the emergency room with a fever, muscle aches, and extreme fatigue. Upon examination of the list of home medications, which medication on the list would prompt further assessment by the nurse? ziprasidone (Geodon) venlafaxine (Effexor) lamotrigine (Lamictal) fluvoxamine (Luvox)
lamotrigine (Lamictal)
Which of the following indicates stimulant intoxication?
meth high, delusion, euphoria, aggression, nausea, self confidence, hot/cold, HR increases Supportive care only, manage symptoms and not fatal just uncomfy
The nurse is reading the provider's admission and sees, "Ms. Smooth reports significant anhedonia over the last six months since her husband died. Which statement by the patient during the nursing assessment matches the provider's documentation?
no longer enjoys watching birds/painting Loss of interest
What is the nurse's priority concern when caring for a bipolar manic patient?
nutrition and fluids
Which of the following statements about naloxone (Narcan) is false?
one dose is not always true
Discharge teaching is complete on a patient who was admitted with schizophrenia. The hormone medications that he is being discharged on include Clozapine (Clozaril). Which statement made by the patient indicates to the nurse that the teaching has been effective in regards to his medications?
potentially fatal side effect of agranulocytosis Develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia
You're the nurse on the inpatient behavioral health unit, caring for 4 patients. Which patient would not be appropriate to consider for group therapy?
pt who is being violent or threatening to harm self or others
After performing a SADPERSONS risk assessment, which finding would the nurse consider to be a risk factor for caring out a suicide plan?
recently separated from a spouse
A client who abuses alcohol has been placed on naltrexone (Vivitrol. What information about the effects of this medication will the nurse include in the client's education?
relapse prevention, suicidal ideation, hepatoxcicity- monitor liver function, reduces the appeal of alcohol
A client with borderline personality disorder is admitted for major depression and non-compliance with medications. On the second night of hospitalization, the client awakens from a nightmare and is yelling at her roommate for "coming at me with that knife you've got hidden." What should the nurse do first to ensure safety?
remove the roommate from the room (safety is always #1)
A client with a family history of diabetes is concerned about the effects of psychiatric medication on the endocrine system. Which psychotropic medication is most likely to cause metabolic syndrome? risperidone (Risperdal) phenelzine (Nardil) isocarboxzid (Marplan) clomipramine (Anafranil)
risperidone (Risperdal)
Which of the following is true about anger, aggression and violence?
unmet needs
46-year old female arrives at the ED brought in by law enforcement after starting a fight with another woman at a local bar and threatening to kill herself. Her blood alcohol is 120. Which question would be the most important for the nurse to ask?
when was your last drink of alcohol
The nurse is caring for a client who is swearing and making verbal threats to other patients and staff. Which is the best response by the nurse to this client's behavior?
you seem pretty upset tell me about, ask the patient to go to their room with you, ensure pt safety
