HESI practice

a nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. which strategies should be included in the safety plan? (sata) - purchase a gun to use for protection - establish a code with family and friends to signify violence - plan an escape route to use if the abuser blocks the main exit - have a big ready that has extra clothes for self and children

- purchase a gun to use for protection - establish a code with family and friends to signify violence - plan an escape route to use if the abuser blocks the main exit - have a big ready that has extra clothes for self and children

which therapeutic communication technique would be useful for a client with major depressive disorder? select all that apply. one, some, or all responses may be correct - reflecting - offering self - using silence - paraphrasing - asking open ended questions - encouraging comparison

- reflecting - offering self - using silence - paraphrasing - asking open ended questions - encouraging comparison (28% students answered correctly)

for clients with mental health disorders, which behavior is most important to prevent? - breaking contracts - ruminating over losses - harming themselves or others - attending to hallucinations

harming themselves or others (95% students answered correctly) (rationale: physical safety of client and others is priority)

a client with long-term cocaine use presents with extreme suspiciousness. which additional clinical manifestations would the nurse monitor for? select all that apply. one, some, or all responses may be correct - extreme hunger - chest pains - panic attacks - nasal damage - severe dental problems

- chest pains - panic attacks - nasal damage (rationaleL with long-term use of cocaine, a central nervous system stimulant, chest pains and panic attacks can occur. nasal damage occurs from snorting cocaine. loss of appetite, rather than extreme hunger, is a short-term side effect. severe dental problems occur with methamphetamine use)

a client comes to the mental health clinic for a monthly injection of 37.5 mg of fluphenazine decanoate. It is available as 25 mg/mL. how many milliliters of solution would the nurse administer? record your answer to one decimal place. ____ mL

1.5 mL (37.5 mg / 25 mg/mL = 1.5 mL)

in which time interval do the most serious life-threatening effects of alcohol withdrawal occur? - 8 to 12 hours - 12 to 24 hours - 24 to 72 hours - 72 to 96 hours

24 to 72 hours (rationale: alcohol withdrawal delirium is a life-threatening central nervous system response to alcohol withdrawal; it occurs in 24 to 72 hours, when the blood alcohol level drops as alcohol is detoxified and excreted)

place the following emergency admission psychiatric assessments and interventions in the order of priority, beginning with the highest priority 1) assess for intent to harm self or others 2) obtain the client's perspective of the situation 3) identify presenting clinical findings 4) collect brief demographic information 5) explore the previous psychosocial history 6) document the collected info on the clinical record

4, 1, 2, 3, 5, 6 (3% students answered correctly)

a client is receiving substitution therapy during withdrawal from benzodiazepines. which expected outcome statement has the highest priority when planning nursing care? - client will not demonstrate cross addiction - co-dependent behaviors will be decreased - CNS stimulation will be reduced - client's level of consciousness will increase

CNS stimulation will be reduced

a male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. his blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. which prescription should the RN administer? - haloperidol (Haldol) - thiamine (Vitamin B1) - diphenhydramine (Benadryl) - lorazepam (Ativan)

lorazepam (Ativan)

on admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. based on this statement, which intervention should the RN include in this client's plan of care? - lead the client by his arm to the seclusion room - ensure the client's environment is safe - schedule activity therapy twice a week - confront his delusion as not consistent with reality

confront his delusion as not consistent with reality

the RN is admitting a male client who take lithium carbonate (eskalith) twice a day. which information should the RN report to the HCP immediately? - short term memory loss - five pound weight gain - decreased affect - nausea and vomiting

nausea and vomiting

which client in a psychiatric unit needs immediate therapeutic intervention? - a 25-year-old man is mimicking the use of a machine gun in front of the nurse's station - a 45-year-old man is sitting quietly in the corner, watching the movements of other clients - a 50-year-old woman is pacing back and forth and picking fights with other clients - a 33-year-old woman is wandering aimlessly around the unit, saying, "I feel so lost."

a 50-year-old woman is pacing back and forth and picking fights with other clients (72% students answered correctly) (rationale: the pacing client is demonstrating increased agitation and poses an immediate threat to the safety of other clients)

the RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. which medication should also be discontinued? - lithium - benzotropine - alprazolam - magnesium

benzotropine

the occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. the employee states, "I can't believe this. what should I do?" which response is best for the RN to provide in this crisis? - tell me what you think should happen - how serious was the collision? - what do you think you should do? - call for transportation to the hospital

call for transportation to the hospital

which behavior would indicate a client with antisocial personality disorder who is facing criminal charges for stealing money from work is meeting treatment outcomes? - expression of feelings of resentment toward the employer - discussion of plans for each of the possible outcomes of a trial - expression of resignation about difficult relationships with coworkers - discussion of the decision to file a grievance against the employer after discharge from the hospital

discussion of plans for each of the possible outcomes of a trial (rationale: if the client can realistically examine the possible outcomes of the trial, then some benefit has been gained from the therapy)

compulsive behavior usually incorporates the use of which defense mechanism? - projection - regression - displacement - rationalization

displacement (rationale: displacement is the unconscious redirection of an emotion from a threatening source to a nonthreatening source)

a woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. she states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. the nurse knows that these behaviors are often associated with which condition? - dissociative disorder - obsessive-compulsive disorder - panic disorder - post-traumatic stress syndrome

dissociative disorder

following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. the client's blood alcohol level is high on admission. which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? - prochlorperazine (compazine) 5 mg IM - hydromorphone (dialuadid) 2 mg IM - chlorpromazine (thorazine) 50 mg IM. - lorazepam (ativan) 2 mg IM

lorazepam (ativan) 2 mg IM

a client who recently experienced the death of a significant other arrives at the mental health center. the client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. which client statement is most important for the RN to explore at this time? - not sleeping for several days - wishing to be with spouse - lack of interest in usual activities - eating very little

not sleeping for several days

narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). within 15 minutes, the client is alert and oriented. in planning nursing care, which intervention has the highest priority at this time? - encourage the client to increase fluid intake - obtain the client's serum vicodin level - observe the client for further narcotic effects - determine the client's reason for attempting suicide

observe the client for further narcotic effects

a female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. what action is most important for the RN to take? - offer the client a safe place to relax before interviewing her - ask the client to describe why she is being stalked - recommend that the client talk with a social worker - assure the client that the HCP will see her today

offer the client a safe place to relax before interviewing her

which activity would the nurse suggest for a client with bipolar disorder, depressive episode, who has been hospitalized on a psychiatric unit for 1 week? - completing a jigsaw puzzle alone - playing cards with several other clients - talking with the nurse several times during the day - engaging in a game of table tennis with another client

talking with the nurse several times during the day (61% students answered correctly) (rationale: the nurse would talk with the client several times during the day. involving the client in a one-on-one conversation provides individualized, low-anxiety-producing attention and gives the message that the client is important, which supports self-esteem)

an adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. while the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? - his appetite - the emotional quality of his attitudes - is level of activity - the interactions he has with others

the emotional quality of his attitudes

which action would the nurse use for a client who is rushing down the hall of the mental health unit, rapidly tapping his fingers against the wall? - approach the client in a nonthreatening manner to determine the cause of the agitation - summon additional staff members to subdue the client and stop the acting-out behavior - observe the client to see whether the behavior escalates and poses a safety risk - obtain staff assistance to administer medication prescribed for the client's agitation

approach the client in a nonthreatening manner to determine the cause of the agitation (75% students answered correctly) (rationale: often helps the agitated client to gain self control)

a client with bulimia and depression who is taking phenelzine (nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. what dietary choices should the RN instruct the client to avoid? - pan-seared catfish - pepperoni pizza - deep fried shrimp - beef trips with gravy

pepperoni pizza

a client with depression remains in bed most of the day, and declines activities. which nursing problem has the greatest priority for this client? - loss of interest in diversional activity - social isolation - refusal to address nutritional needs - low self-esteem

refusal to address nutritional needs

which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit? - make the client mop the floor - restrict the client's fluids for the rest of the day - toilet the client more frequently with supervision - withhold the client's privileges zach time the client voids on the floor

toilet the client more frequently with supervision (96% students answered correctly)

a male client in the mental health unit is guarded and vaguely answers the nurse's questions. he isolates in his room and sometimes opens the door to peek into the hall. which problem can the RN anticipate? - visual hallucinations - auditory hallucinations - excessive motor activity - delusions of persecution

delusions of persecution

for clients who have severe psychiatric disorders, which therapeutic outcome is anticipated for the majority of prescribed antipsychotic medications? - improvement of judgement and cognition - improvement of verbal and social skills - elimination of neurotic signs and symptoms - management of hallucinations and delusions

management of hallucinations and delusions (63% students answered correctly) (rationale: antipsychotics are a class of medications primarily used to manage the positive s/s associated with psychoses, including hallucinations, delusions, paranoia, and disorganized speech)

which actions by the staff of a mental health unit can lead to client violence? select all that apply. one, some, or all responses may be correct - displaying hyperactivity - inconsistent limit setting - controlling staff members - avoiding direct eye contact - randomly taking away privileges

- inconsistent limit setting - controlling staff members - randomly taking away privileges (24% students answered correctly)

tThe nurse discusses basic neurotransmitter theory with students during their mental health rotation. education will be deemed successful if the students identify that a decrease in gamma-aminobutyric acid (GABA) will result in which outcome? - anxiety - depression - paranoid schizophrenia - dementia of the alzheimer type

anxiety (63% students answered correctly) (rationale: a decrease in GABA results in anxiety, according to the basic neurotransmitter theory; antianxiety medications activate GABA receptors, thus opening chloride ion channels and easing anxiety)

which statement would the nurse make when discharging a depressed client from the mental health unit? - "i'm going to miss you; we've become good friends." - "i know that you're going to be all right when you go home." - "call the contact number we gave you if you have an emergency." - "this is my phone number; call and let me know how you're doing."

"call the contact number we gave you if you have an emergency." (92% students answered correctly)

a client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. what is the most therapeutic response for the RN to provide/ - "let's go ask another RN is this is true." - "my name tag shows that I am a RN here." - "I can't possibly be one if your children." - "I know that you don't have 20 children."

"my name tag shows that I am a RN here."

the nurse is working with a group of clients in a mental health facility. the nurse would assess risk for suicide in clients with which conditions? select all that apply. one, some, or all responses may be correct - anxiety - alcohol abuse - schizophrenia - bipolar disorder - attention deficit disorder

- anxiety - alcohol abuse - schizophrenia - bipolar disorder (34% students answered correctly)

a male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he was divorced one year ago. lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client's current feelings of depression? - feelings of frustration - a sense of loss - poor self-esteem - a lack of intimate relationships

a sense of loss

the RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. what intervention is most important for the RN to implement? - don't allow the client to go into the kitchen until the hallucination has subsided - report the behavior to the client's case workers so that the family can be notified - assign the UAP to remain with the client at all times - document the behavior in the client's record and notify the HCP

assign the UAP to remain with the client at all times

when discussing standards for involuntary admission to a mental health facility, which factor is related to safety? - mental illness - severe disability - currently cutting - needs treatment

currently cutting (84% students answered correctly) (rationale: client who is a danger to themselves or others is a safety factor that would necessitate involuntary admission to a facility)

which thought process would the nurse document the mental health client is experiencing after the client says, "The FBI is out to kill me"? - hallucinations - error in judgement - delusion of persecution - self accusatory delusion

delusion of persecution (87% students answered correctly)

a client on the psychiatric unit says, "I'm a movie star, and the other clients are my audience." which thought process would the nurse document the client is experiencing? - flight of ideas - referential delusions - delusions of grandeur - auditory hallucination

delusions of grandeur (89% students answered correctly)

which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? - client's medication history includes the frequent use of antidepressants - describe self as a social drinker who drinks alcoholic beverages daily - reports difficulties with short term memory since traumatic brain injury - medical history includes that the client was recently sexually assaulted

describe self as a social drinker who drinks alcoholic beverages daily

an older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). during the health assessment, the client complains of chest pain. which action should the RN take first? - refer the client to the cardiology unit - obtain the client blood pressure - assess the client for substance abuse - determine if xanax was taken recently

determine if xanax was taken recently

a male adult is admitted because of an acetaminophen (Tylenol) overdose. after transfer to the mental health unit, the client is told he has liver damage. which information is most important for the nurse to include in the client's discharge plan? - do not take any over the counter meds - eat a high carb, low fat, low protein diet - call the crisis hotline if feeling lonely - avoid exposure to large crowds

do not take any over the counter meds

a male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (geodon) one month ago. which question is most important for the RN to ask the client? - have you lost interest in the things that you used to enjoy? - is your ability to think or concentrate decreased? - how many continuous hours do you sleep at night? - do you hear sounds or voices that others do not hear

do you hear sounds or voices that others do not hear

which action would the nurse encourage for a female client with emotional problems who is being discharged from a psychiatric unit? - go back to regular activities - enroll in an aftercare program - call the unit whenever she is upset - find a group that has similar problems

enroll in an aftercare program (63% students answered correctly) (rationale: close follow-up and continued monitoring of medication, behavior, and emotional state are necessary to enable the client to maintain a positive behavioral change. returning to regular activities depends on what the client's regular activities were. an open invitation to call the unit encourages dependence. a self-help group may be part of aftercare planning, but follow-up regarding medications and individual psychotherapy should be considered first)

teveral clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. the RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. what is the priority issue that the RN should address? - medication non-compliance - number of bathroom facilities - infection control - acting out behaviors

infection control

which short-term nursing objective would be essential for a client with agoraphobia who is admitted to the psychiatric unit of a local hospital? - feeling safe in the unit - increasing self esteem - going out unaccompanied - being comfortable in groups

feeling safe in the unit (81% students answered correctly) (rationale: the essential nursing objective is for the client to feel safe in the unit. a calm, quiet, nonthreatening, supportive environment eases anxiety and decreases the need to use maladaptive coping techniques. increased self-esteem is a long-term objective. going out unaccompanied and feeling comfortable in groups are long-term objectives; at this time, they will only increase anxiety.)

which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? - at least I hit the wall instead of hitting the psychiatric aide - i am here because the police thought I was doing something wrong - i want to be here because I know it is the best psychiatric facility - don't believe everything my family tells you, I am not crazy

i am here because the police thought I was doing something wrong

which essential, initial interventions would be included in the plan of care for a client admitted to the psychiatric unit during the first episode of an acute psychotic disorder? - assessing the symptoms and teaching the client about the disorder - encouraging participation in cognitive enhancement and providing social skills enhancement - maintaining a daily routine and instituting family and group therapies - instituting psychopharmacological prescriptions and offering supportive communication

instituting psychopharmacological prescriptions and offering supportive communication (45% students answered correctly) (rationale: this is the essential intervention)

which action would the nurse take to help a client participate in an activity whose depression is beginning to lift but remains aloof from the other clients on the mental health unit? - find solitary pursuits that the client can enjoy - speak to the client about the importance of entering into activities - ask the primary HCP to speak to the client about participating - invite another client to take part in a joint activity with the nurse and client

invite another client to take part in a joint activity with the nurse and client (68% students answered correctly) (rationale: the nurse would invite another client to take part in a joint activity with the nurse and the client. bringing another client into a set situation is the most therapeutic, least threatening approach)

a mental health worker is caring for a client with escalating aggressive behavior. which action by the mental health worker warrants immediate intervention by the RN? - is attempting the physically restrain the patient - remains at a distance of 4 feet from the client - tells the client to go to the quiet area of the unit - is using a load voice to talk to the client

is attempting the physically restrain the patient

a mental health worker is caring for a client with escalating aggressive behavior. which action by the MHW warrant immediate intervention by the RN? - is attempting to physically restrain the patient - tells the client to go to the quiet area of the unit - is using a loud voice to talk to the client - remains at a distance of 4 feet from the client

is attempting to physically restrain the patient

the nurse is administering a prescribed antidepressant medication to a client in an inpatient mental health facility. which action would the nurse perform to ensure the client is not stashing doses of medication? - provide a 1:1 sitter for the client - observe the client swallowing the medication - ask a client's family member to ensure the dose is taken - set the correct medication dose on the client's meal tray

observe the client swallowing the medication (92% students answered correctly) (rationale: clients in inpatient mental health facilities may attempt to stash doses of prescribed medication for use in a suicide attempt. the nurse will need to watch the client to ensure the medication is swallowed and not "cheeked." it is the nurse's responsibility to oversee medication administration, not a sitter or family member)

the RN completes an assessment of a client who is experiencing intimate partner violence (IPV). which finding of the injuries should the RN include in the documentation? - a summary of the client's feelings - photographs - a general description - a client's significant other's statement

photographs

the RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). what information should the client acknowledge understanding? - completely abstain from heroin or cocaine use - remain alcohol free for 12 hours prior to the first dose - attend monthly meetings of alcoholics anonymous - admit to others that he is a substance user

remain alcohol free for 12 hours prior to the first dose

which therapeutic communication strategy is involved when the older client is recalling the past? - touch - reminiscence - reality orientation - validation therapy

reminiscence (92% students answered correctly) (rationale: involves recalling and discussing past experiences)

a male veteran who recently returned from a war zone has post traumatic stress disorder (ptsd) and is admitted to the psychiatric ward because of admitted suicidal ideation. on admission, the client's family informed the hcp that therapy sessions did not seem to be helping. select only one intervention that as the highest priority? - administer paraxeitne 40 mg as prescribed - develop a list of therapy programs - remove all shaving equipment - determine if client has a suicide plan

remove all shaving equipment

which action would the nurse take firstfor a client who comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing? - stay physically close to the client - gently ask what is bothering the client - tell the client to try to relax by sitting quietly - get the client involved in a nonthreatening activity

stay physically close to the client (48% students answered correctly) (rationale: by staying physically close to the client during the time of severe anxiety, the nurse conveys the message that someone cares enough to be there during this frightening incident and that the client is a person worthy of care)

a female client admitted to the mental health unit starts to shout and scream at the RN. what is the best approach for the RN to take? - stay quietly with the patient - tell her that she is out of control - distract her by offering her finger foods - ignore the client's acting out behavior

stay quietly with the patient

a middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. which intervention is likely to be most effective in returning this client to a normal level of functioning? - provide education on methods to enhance sleep - teach the client to develop a plan for daily structured activities - suggest that the client develop a list of pleasurable activities - encourage the client to exercise

teach the client to develop a plan for daily structured activities

during admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. what intervention is most important for the RN to implement during the admission process? - assist the client in developing alternative coping skills - remain calm and use a matter of fact approach - ask the client why she is so anxious - administer a PRN sedative to help relieve her anxiety

assist the client in developing alternative coping skills

a client who uses ritualistic behavior taps other clients on the shoulders three times as part of the ritual. Which rationale best explains the client's behavior? - client demonstrates blurred personal identity - client has poor control of sudden urges - client has a disturbance in spatial boundaries - client has limited ability to adapt to stressors

client has limited ability to adapt to stressors (51% students answered correctly) (rationale: ineffective coping is the impairment of a person's adaptive behaviors and problem-solving abilities in meeting life's demands; ritualistic behavior is an impaired type of coping)

which intervention would provide the greatest safety for a client admitted to a mental health unit because of suicidal ideation? - seclusion room - four point restraints - continual one on one supervision - removal of unsafe objects from the environment

continual one on one supervision (63% students answered correctly)

which goal is applicable to adolescents with conduct disorder? - increased impulse control and ability to focus - identification of two positive personal attributes - demonstration of respect for the rights of others - age-appropriate play activities with at least one peer

demonstration of respect for the rights of others (rationale: demonstrating respect for the rights of others is a specific outcome criterion for children with the diagnosis of conduct disorder; these children typically present with repetitive and persistent behaviors that violate the basic rights of others or age-appropriate societal norms or rules)

which mental health client would be at highest risk for assaultive behavior? - uses profane language - touches people excessively - exhibits a sudden withdrawal - experiences command hallucinations

experiences command hallucinations (71% students answered correctly) (rationale: dangerous because they may influence the client to engage in behaviors that are dangerous to self or others)

the nurse is interviewing a client in the mental health clinic. which statement by the client indicates an irreversible adverse response to long-term therapy with an antipsychotic medication? - "my mouth is always dry" - "I can't seem to sleep at night" - "I don't have much of an appetite" - "I cannot control my tongue movements"

"I cannot control my tongue movements" (90% students answered correctly) (rationale: characteristic of tardive dyskinesia which is an irreversible, antipsychotic med induced neuro d/o)

a client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." the RN should plan one-on-one observation of the client based on which statement? - "what should I do? nothing seems to help." - "I have been so tired lately and needed to sleep." - "I really think that I don't need to be here." - "I don't want to walk. nothing matters anymore."

"I don't want to walk. nothing matters anymore."

which nursing actions are likely to help promote the self-esteem of a male client with modern depression? - ask the client what his long term goals are - discuss the challenges of his medical condition - include the client in determining treatment protocol - encourage the client to engage in recreational therapy - provide opportunities for the client to discuss his concerns

- ask the client what his long term goals are - encourage the client to engage in recreational therapy - provide opportunities for the client to discuss his concerns

which reason would likely be the cause for a 65-inch (165 cm) tall 15-year-old girl weighing 80 lb (36.3 kg) being admitted to a mental health facility? - a desire to control her life - the wish to be accepted by her peers - the media's emphasis on the beauty of thinness - a delusion in which she believes that she must be thin

a desire to control her life (32% students answered correctly) (rationale: eating and weight loss become the means of control to decrease anxiety related to distorted thinking. controlling one's self is more likely the cause than peer group acceptance)

the nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. which medication should also be discontinued? - alprazolam (xanax) - benztropine (cogentin) - magnesium (milk of magneisa) - lithium (lathotbabs)

benztropine (cogentin)

a client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. based on which assessment finding will the RN withhold the clonidine (catapres) prescription? - blood pressure readings of 90/62 mmHg to 92/58 mmHg - pulse rate of 68-78 BPM - temperature of 99.5-99.7 F - respiration rate of 24 breaths per minute

blood pressure readings of 90/62 mmHg to 92/58 mmHg

a client who is known to abuse drugs is admitted to the psychiatric unit. which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? - perphenazine (trilafon) - diphenylhydramine (benadryl) - chlordiazepoxide (librium) - isocarboxazid (marplan)

chlordiazepoxide (librium)

which therapeutic communication technique is demonstrated when the nurse says, "i'm confused about exactly what is upsetting you. would you go over that again, please?" - clarifying - structuring - confronting - paraphrasing

clarifying (97% students answered correctly)

which long-term outcome would be appropriate for a client with severe rheumatoid arthritis who becomes depressed and is admitted to the psychiatric unit? - eats at least 2 meals per day with other clients - maintains self care while attending structured activities - makes a positive verbal comment to another client daily - decreases negative thinking about self, others, and life

decreases negative thinking about self, others, and life (55% students answered correctly) (rationale: the long-term outcome is to decrease negative thinking about self, other, and life. the long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged)

which therapeutic communication technique is used when the nurse and a client have a conversation and the client begins to repeat the conversation to her- or himself? - focusing - clarifying - paraphrasing - summarizing

focusing (33% students answered correctly)

a client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. what action should the nurse take? - notify the physician immediately and force fluids - prior to giving the next dose, notify the physician of the symptoms - record the symptoms and continue medication as prescribed - hold the medication and refuse to administer additional amounts of the drug

prior to giving the next dose, notify the physician of the symptoms

an anxious, panicked client states, "I admitted myself because I think I'm going crazy." which interpretation would the nurse make about the client's remark? - this is a plea for support - the client has insight - this is a symptom of depression - the client is testing the nurse's trust

this is a plea for support

the Rn is planning client teaching for a 35-year-old client with alcoholic cirrhosis. which self- care measure should the RN emphasize for the client's recovery? - support group meetings. - vitamin B and multivitamin supplements - diet with adequate calories and protein - alcohol abstinence

alcohol abstinence

the RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. which finding requires notification to the HCP? - potassium level of 2.9 mEq/dl - blood pressure of 110/70 mmHg - WBC of 10,000mm^3 - body mass index of 21

potassium level of 2.9 mEq/dl

which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? - sharing hope - sharing humor - sharing empathy - sharing observations

sharing humor (52% students answered correctly) (rationale: sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress)

the nurse manager is discussing ways to maintain staff safety in a client mental health unit. which action by the nurse indicates a need for further education? - the nurse wears a stethoscope around the neck - the nurse moves furniture and removes obstacles in area - the nurse removes items from the area that can cause harm - the nurse stands away from the doorway when talking with a client

the nurse wears a stethoscope around the neck (79% students answered correctly)

during an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. he further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers. how should the RN respond? - "anger is contagious and could result in major confrontation." - "try not to let your anger cause you to act impulsively." - "expressing your anger to a stranger could result in an unsafe situation." - "it sounds as if there are many situations that make you feel angry."

"it sounds as if there are many situations that make you feel angry."

a 10-year-old child who has head lice tells the school nurse, "i'm mad because my mother said I got lice because I don't keep myself clean." which would the nurse communicate to initiate therapeutic communication about this subject? - "it sounds as if you feel that your mother is putting you down." - "there is a relationship between cleanliness and lice infestation." - "you and your mother must be having problems getting along." - "people who don't keep themselves clean are more likely to get lice."

"it sounds as if you feel that your mother is putting you down." (82% students answered correctly) (rationale: asking whether the child feels put down focuses on the child's perceptions and promotes further communication)

which characteristics of affect are expected for a client with the diagnosis of somatoform disorder, conversion type? select all that apply. one, some, or all responses may be correct - calm - cheerful - depressed - frightened - matter of fact

- calm - matter of fact (rationale: emotional conflicts are transferred to physical symptoms; thus the symptoms reduce anxiety and remove the conflict. the individual demonstrates a lack of concern about the symptoms (la belle indifférence))

a 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. which action should the nurse implement? - encourage the client to actively participate in assigned activities on the unit - place a lock on the client's closet - ignore the client's paranoid ideation to extinguish these behaviors - explain to the client that his suspicions are false

encourage the client to actively participate in assigned activities on the unit

a high school girl reveals to the high school RN that she has been engaging in self-induced vomiting as weight-control measure. which initial assessment should the RN focus on with this adolescent? - national percentile of weight and height - frequency of bingeing and purging behaviors - perceptions of family and social relationships - school grades and extracurricular activities

frequency of bingeing and purging behaviors

a client is admitted with a diagnosis of depression. the nurse knows that which characteristic is most indicative of depression? - grandiose ideation - self-destructive thoughts - suspiciousness of others - a negative view of self and the future

a negative view of self and the future

an uncooperative client elopes from the acute care psychiatric unit. which immediate action would the charge nurse use? - pursue the eloping client and escort the client back to the unit - send an unlicensed assistive personnel to bring the client back to the unit - call the police and report the eloping client as a missing person - ask hospital security to accompany a licensed nurse to retrieve the client

ask hospital security to accompany a licensed nurse to retrieve the client (58% students answered correctly) (rationale: having hospital security accompany a licensed nurse is the best action to ensure the safety of the client and the nurse. as a general rule, 1 staff member shouldn't attempt to restrain or return an uncooperative client to a unit)

the nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. what should the nurse do first while taking the client's history upon admission to the hospital? - determine if the client attends a support group weekly - hold all antidepressant medications until further notice - ask the client if he takes st. john's wort routinely - have the client describe any recent changes in mood

ask the client if he takes st. john's wort routinely

a client is admitted voluntarily to a psychiatric unit for severe depression. later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. how would the nurse prepare the client for the appendectomy? - have two nurses witness the client signing the operative consent form - ensure that the primary health care provider and the psychiatrist sign for the surgery because it is an emergency procedure - ask the client to sign the operative consent form after the client has been informed of the procedure by the health care provider - inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit

ask the client to sign the operative consent form after the client has been informed of the procedure by the health care provider (77% students answered correctly) (because the client isn't certified as incompetent, the right of informed consent is retained)

a female client reports feeling hopeless and is unable to stop crying. she explains that she is worried about losing her job. since the client's husband recently lost his job she feels her employment is essential to the family's survival. to evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care? - relates insight into problematic relationships - demonstrates a healthy relationship with husband - described how the family can resolve problem - changes thought patterns related to problem solving

changes thought patterns related to problem solving

the details of four clients with psychiatric disorders are given below. which client can be indicated for the administration of mood stabilizers? - client A: 15 y/o, anorexia - client B: 10 y/o, enuresis - client C: 35 y/o, OCD - client D: 25 y/o, bipolar disease

client D: 25 y/o, bipolar disease (91% students answered correctly) (rationale: mood stabilizers such as lithium salts are indicated for clients with bipolar disease. tricyclic antidepressants are indicated for the other conditions)

which action would the nurse take when shortly after admission to a mental health unit an adolescent falls to the floor and exhibits tonic-clonic movements but still continues to chew gum? - remove the chewing gum - document the observation - send another client for help - insert a tongue blade between the teeth

document the observation (57% students answered correctly) (rationale: if seizures were physiologically based, the client would not be able to continue chewing gum. this "attack" should be reported as a behavioral response)

a female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. the afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. what action should the nurse implement? - explain to the client that her behavior invades the rights of the nursing staff - ask the client to explain why she is keeping a detailed record of her nursing care - teach the client strategies to control her obsessive compulsive behavior - encourage the client to express her feelings regarding the upcoming procedure

encourage the client to express her feelings regarding the upcoming procedure

a male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. what intervention is best for the RN to implement? - isolate the client from the other clients - administer PRN sedative - avoid recognizing the behavior - escort the client to his room

escort the client to his room

a male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. that intervention is best for the nurse to implement? - avoid recognizing the behavior - isolate the client from other clients - administer a PRN sedative - escort the client to his room

escort the client to his room

a client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. which intervention has the highest priority for this client's plan of care? - encourage substitution of positive thoughts and negative ones - establish trust by providing a calm, safe environment - progressively expose the client to larger crowds - encourage deep breathing when anxiety escalates in a crowd

establish trust by providing a calm, safe environment

the nurse is going through a pilot research study that aims to identify the effectiveness of using an experimental therapeutic communication technique when dealing with aggressive clients. this describes which type of study? - evaluation research - exploratory research - descriptive research - correlational research

exploratory research (76% students answered correctly) (rationale: exploratory research studies are initial studies that are conducted to develop or refine dimensions of phenomena or to develop a hypothesis about the relationships among phenomena)

a male client comes to the emergency center because he has an erection that will not resolve. the client reports that he is taking trazodone (Desyrel) for insomnia. which information is most important for the nurse ask the client? - when was the last time you drank alcoholic beverage? - have you taken any medications for erectile dysfunction? - are you having any other sexual dysfunctions or problems? - do you have a history of angina or high blood pressure?

have you taken any medications for erectile dysfunction?

which action would the nurse implement for a client with somatic symptoms? select all that apply. one, some, or all responses may be correct. - scheduling office visits once a year - having the client direct all requests to the case manager - reminding the client who is in charge of their care - conducting a physical examination only when necessary - explaining to the client that the symptoms aren't real - taking vital signs each time the client complains of symptoms

having the client direct all requests to the case manager (7% students answered correctly) (rationale: clients with somatic symptoms would be instructed to direct all requests to the case manager to reduce manipulation)

a college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. during the interview, what nursing intervention should take the highest priority? - identify support systems in the community that may be helpful - help the client feel safe to decrease anxiety - ask the client to describe coping strategies that were helpful in the past - encourage the client to verbalize anxiety related to event

help the client feel safe to decrease anxiety

a he RN is leading a group on the inpatient psychiatric unit. which approach should the RN use during the working phase of group development? - establishing a rapport with group members - clarifying the nurse's role and clients' responsibilities - discussing ways to use new coping skills learned - helping clients identify areas of problem in their lives

helping clients identify areas of problem in their lives

the nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. when the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "get out of here! I'll get up when I'm ready!" which response is best for the nurse to make? - your healthcare provider has prescribed ambulation on the first postoperative day - you must ambulate to avoid complications which could cause more discomfort than ambulating - i know how you feel. you're angry about having to ambulate, but this will help you get well - i'll be back in 30 minutes to help you get out of bed and walk around the room

i'll be back in 30 minutes to help you get out of bed and walk around the room

when preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. what action should the RN take? - tell him to take the medication then verify the dosage at the next healthcare team meeting - withhold the medication until the dosage can be confirmed - inform him that he may refuse the medication and document whether or not he takes it - explain to the client that the dosage has been changed

inform him that he may refuse the medication and document whether or not he takes it

a teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. the client reports irregular menses and hair loss. which intervention is most important for the RN to include in the clients plan of care? - implement behavioral modification therapy - initiate caloric and nutritional therapy - evaluate the client for low self-esteem - record daily weights and graft trend

initiate caloric and nutritional therapy

a young adult male is hospitalized due to depression and an attempted suicide attempt. the client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. which behavior best indicates to the nurse that his condition is improving? - initiates interactions with other clients - describes verbally when he is angry - participates in a job search with a social worker - denies plans to harm himself or others

initiates interactions with other clients

the RN documents the mental status of a female client who has been hospitalized for several days by court order. the client states, "I don't need to be here" and tells the RN that she believes the television talks to her. the RN should document these assessment findings in which section of the mental status exam/ - level of concentration - insight and judgement - remote memory - mood and affect

insight and judgement

a client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol tablets orally to reduce agitation and preoccupation with auditory hallucinations. there has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. which intervention will the nurse take? - ask the HCP to change the medication - make certain that the client is swallowing the medication - conclude that therapeutic failure has occurred - secure a prescription for an as-needed sedation until the client calms down

make certain that the client is swallowing the medication (84% students answered correctly) (rationale: because the med is taken orally, the client may be pocketing the media the buccal cavity and discarding it later)

a client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. which intervention during the first 6 hours following admission should the RN identify as the priority? - give lorazepam (Ativan) PRN for signs of withdrawal - administer disulfiram (Antabuse) immediately - place in a side lying position with head of bed elevated - provide thiamine and folate supplements as prescribed

place in a side lying position with head of bed elevated

a female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. what action should the nurse take? - discuss checking the time frequently - ask the client why she checks the locks - plan a list of activities to be carried out daily - determine the type and size of the locks

plan a list of activities to be carried out daily

a client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. the client stopped taking prescribed antipsychotic drugs approximately one month ago. since hospitalization the client continues to have poor judgment and refuses all medications. what action should the RN take? - encourage the client to stay in the hospital so the client does not have to be homeless - provide the client with medication if the client presents an imminent risk to self and others - administer a long acting antipsychotic medication so that the client can be discharged to a shelter - describe to the client treatment options provided at the community mental health clinics

provide the client with medication if the client presents an imminent risk to self and others

a client with a diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine medication. when the psychiatric daycare center plans a fishing trip, it will be important for the nurse to take which action? - provide the client with sunscreen - caution the client to limit exertion during the trip - give the client an extra dose of medication to take after lunch - take the client's BP before allowing participation in the outing

provide the client with sunscreen (83% students answered correctly) (rationale: phenothiazines commonly cause a photosensitivity that can be controlled with sunscreen)

which communication technique is a part of therapeutic communication? - asking for explanations - showing sympathy to the client - asking personal questions of the client - providing relevant information to the client

providing relevant information to the client (34% students answered correctly) (rationale: because clients have the right to know about their health status, the nurse would provide them with all relevant information. this is a therapeutic communication technique that enables clients to understand what is happening and what to expect. asking for explanations, showing sympathy, and asking personal questions of the client are nontherapeutic communication techniques)

a male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. which intervention should the RN implement? - report the client's serum lithium level to the HCP - encourage the client to suck on hard candy to relieve the symptoms - no action is needed since polydipsia is a common side effect - tell the client that drinking from the faucet is not allowed

report the client's serum lithium level to the HCP

an antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? - meet scheduled appointment with dietitian - sleep at least 6 hours a night - understands the purpose of the medication regimen - describes the reasons for hospitalization

sleep at least 6 hours a night

a male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. which priority nursing problem should the RN include in the client's plan of care? - risk for suicide - sleep deprivation - situational low self-esteem - social isolation

sleep deprivation

which primary purpose is served when a group of clients from a psychiatric unit are accompanied by staff members to go a professional baseball game? - clients can observe how other people interact in a community setting - community members get exposed to psychiatric clients under supervision - clients' experiences are broadened by providing exposure to cultural activities - staff members can observe the clients' abilities to cope with a more complex society

staff members can observe the clients' abilities to cope with a more complex society (65% students answered correctly) (rationale: the staff members' observations can help identify those clients who are ready to cope with outside stress and those who are not. benefits can come from: observing the behaviors of others in a social setting, positive interactions between community members and clients, and broadening cultural experiences; however, these additional benefits are not the primary purpose of supervised community outings)

a middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. which intervention is like to be most effective in returning this client to a normal level of functioning? - encourage the client to exercise - suggest that the client develop a list of pleasurable activities - provide education on methods to enhance sleep - teach the client to develop a plan for daily structured activities

teach the client to develop a plan for daily structured activities

while interviewing a client, the nurse takes notes to assist with accurate documentation later. which statement is most accurate regarding note-taking during an interview? - the client's comfort level is increased when the RN breaks eye contact to take notes - the interview process is enhanced with note taking and allows the client to speak at a normal pace - taking notes during an interview is a legal obligation of examining RN - the RN's ability to directly observe the client's non-verbal communication is limited with note taking

the RN's ability to directly observe the client's non-verbal communication is limited with note taking

which initial inference would the nurse make about a psychiatric client curled up in the fetal position in the corner of the dayroom? - the client is feeling more anxious today - the client is trying to hide from staff - the client is tired and probably did not sleep well last night - the client is physically ill and experiencing abdominal discomfort

the client is feeling more anxious today (84% students answered correctly) (rationale: the fetal position represents regressive behavior; regression is a way of responding to overwhelming anxiety. no initial data are available to indicate that the client is trying to hide, is tired, or is physically ill)

while interviewing a client, the nurse takes notes to assist with accurate documentation later. which statement is most accurate regarding note-taking during an interview? - the nurse' ability to directly observe the client's nonverbal communication is limited with note taking - taking notes during an interview is a legal obligation of the examining nurse - the client's comfort level is increased when the nurse breaks eye contact to take note to take note - the interview process is enhanced with note taking and allows the client speak at normal pace

the nurse' ability to directly observe the client's nonverbal communication is limited with note taking

the nurse is caring for several clients with major thought disorders such as those occurring in clients with schizophrenia. they are all being treated with neuroleptic medications. how do these medications act in the body to promote mental health? - they inhibit enzymes at the postsynaptic receptor site - they decrease serotonin at the postsynaptic receptor site - they increase dopamine uptake at the postsynaptic receptor site - they block access to dopamine receptors at the postsynaptic receptor site

they block access to dopamine receptors at the postsynaptic receptor site (63% students answered correctly) (rationale: neuroleptics block access to dopamine receptors, rather than inhibiting enzymes and they increase - not decrease - serotonin at the sites)

a newly admitted client quietly listens to the nurse's explanation of the mental health unit and then says, "so this is where they keep the crazies." which response would the nurse use? - "these people are emotionally ill; we never use words like crazy or nuts." - "some people feel that way. let's talk about mental health." - "would you like me to explain the philosophy of psychiatric care?" - "do you feel that a person has to be crazy to need mental health services?"

"do you feel that a person has to be crazy to need mental health services?" (53% students answered correctly) (rationale: nurse is reflecting the specific fear of being 'crazy' and invites discussion about the client's misconceptions of mental health services)

which response would the nurse make to a client with a history of obsessive-compulsive behaviors who on the day of the part-time job interview arrives at the mental health center with signs of anxiety? - "i know you're anxious, but by forcing yourself to go to the interview you may conquer your fear." - "if going to an interview makes you this anxious, you're probably not ready to go back to work." - "it must be that you really don't want that job after all. i think you should reconsider going to the interview." - "going for your interview triggered some feelings in you. perhaps you could call a friend to drive you there."

"going for your interview triggered some feelings in you. perhaps you could call a friend to drive you there." (80% students answered correctly)

when developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? - impaired comfort - risk for injury - ineffective breathing pattern - ineffective coping

ineffective breathing pattern

for a client who has a moderate level of cognitive impairment as a result of dementia, which finding is expected? - hypervigilance - increased inhibition - enhanced intelligence - accentuated premorbid traits

accentuated premorbid traits (rationale: a moderate level of cognitive impairmentbecause of dementia is characterized by increasing dependence on environmental and social structure and by increasing psychological rigidity with accentuated previous traits and behavior)

an anxious client expressing a fear of people and open places is admitted to the psychiatric unit. what is the most effective way for the nurse to assist this client? - plan an outing within the first week of admission - distract her whenever she expresses her discomfort about being with others - confront her fears and discuss the possible causes of these fears - accompany her outside for an increasing amount of time each day

accompany her outside for an increasing amount of time each day

which diet selection by a depressed client taking tranylcypromine sulfate (parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? - hamburger, french fries, and chocolate milkshake - liver and onions, broccoli, and decaffeinated coffee. - pepperoni and cheese pizza, tossed salad, and soda - roast beef, baked potato with butter, and iced tea

pepperoni and cheese pizza, tossed salad, and soda

which nurse statement defines boundaries in the orientation phase of the nurse-client relationship, when talking to a depressed client who has just been admitted to the psychiatric unit? - "tell me about the relationship that you have with your mother and father." - "hello! I'm nurse andrea. i'll introduce you around and help you settle in." - "what is the main thing that you would like to work on during therapy?" - "I understand that you have been depressed. what can you tell me about that?"

"hello! I'm nurse andrea. i'll introduce you around and help you settle in." (58% students answered correctly) (rationale: boundaries define and separate the self from the client and indicate one's responsibilities in relation to the other individual)

which statement demonstrates that a psychiatric nurse has successfully fostered a therapeutic nurse-client relationship? - "my clients and I are partners in the planning that helps meet their physical and mental health needs." - "nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." - "mental health is achieved and maintained when the nurses and the clients exhibit respect and caring for each other." - "without a mutually satisfying relationship between nurse and client, achieving mental and physical wellness is very difficult."

"my clients and I are partners in the planning that helps meet their physical and mental health needs." (64% students answered correctly) (rationale: a truly therapeutic nurse-client relationship provides satisfaction for both nurse and client. if that is not achievable, nursing care is provided to help the client maximize potential in physical and mental health)

which statement by the nurse reflects understanding of therapeutic communication with a client experiencing domestic violence? select all that apply. one, some, or all responses may be correct. - "tell me about your struggles" - "everything is going to be okay" - "get out of the house right away" - "you'll feel better after you leave" - "why do you stay when he hits you?" - "why did you return to him after the abuse?"

"tell me about your struggles" (63% students answered correctly) (rationale: "tell me about your struggles," is therapeutic communication, as it encourages a client to describe their perception. talking about feelings can help clients clarify their thoughts)

a client on a psychiatric unit who has auditory hallucinations is receiving a neuroleptic medication for the first time. the client takes the cup of water and the pill and stares at them. which statement by the nurse is therapeutic? - "you have to take your medicine" - "this is the medication that your HCP prescribed" - "this will help you not to hear the voices. it will only work if you take it" - "there must be a reason that you don't want to take your medicine"

"this will help you not to hear the voices. it will only work if you take it" (65% students answered correctly) (rationale: explaining what the medication will do for the client is an appropriate nursing intervention)

which questions would the nurse ask when assessing the mental health of a preschool-aged client? select all that apply. one, some, or all responses may be correct - "is your child experiencing nightmares?" - "does your child ask questions about the genitalia?" - "does your child wear a helmet when riding a bicycle?" - "how do you implement punishment when a rule is broken?" - "is your child up to date on the recommended immunizations?"

- "is your child experiencing nightmares?" - "does your child ask questions about the genitalia?" - "how do you implement punishment when a rule is broken?" (52% students answered correctly) (rationale: these are all appropriate questions for preschool aged clients, but not all of them specifically address mental health issues, some are safety or health promotion issues)

the home health nurse assesses the client with acquired immunodeficiency syndrome (AIDS) for which signs of altered mental health function associated with AIDS? select all that apply. one, some, or all responses may be correct - delusions - memory loss - hopelessness - hyperactivity - paranoid thinking

- delusions - memory loss - hopelessness - paranoid thinking (16% students answered correctly) (rationale: clients experience a decrease in energy)

effective therapeutic communication would directly affect which outcomes for a client who has schizophrenia? select all that apply. one, some, or all responses may be correct - becomes capable of part time employment - effectively expresses emotional and physical needs - demonstrates wellness reflective of physical potential - demonstrates an understanding of the mental health disorder - recognizes the issues most important to managing this disorder

- effectively expresses emotional and physical needs - demonstrates an understanding of the mental health disorder - recognizes the issues most important to managing this disorder (41% students answered correctly)

the RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. which strategies should be included in the safety plan? (SOA) - purchase a gun to use for protection - establish a code with family and friends to signify violence - take a self-defense course that retaliates the abuser with injury - have a bag ready that has extra clothes for self and children - plan an escape route to use if the abuser blocks the main exit

- establish a code with family and friends to signify violence - have a bag ready that has extra clothes for self and children - plan an escape route to use if the abuser blocks the main exit

which considerations would the mental health nurse keep in mind when preparing to meet with a group of staff nurses who cared for victims of a disaster that occurred in the community? select all that apply. one, some, or all responses may be correct - organize the chairs in a circle - plan to meet for 1-3 hours - set up the audio taping machine - ensure food and drinks are available - use the organization auditorium for the session

- organize the chairs in a circle - plan to meet for 1-3 hours - ensure food and drinks are available (44% students answered correctly) (rationale: typical "ground rules" for stress debriefing include strict confidentiality of information shared during the session and unconditional acceptance of the thoughts and feelings expressed by people within the group. this means that the session should not be audiotaped. the setting should be private. an auditorium would not be private)

which interventions will assist in creating and maintaining a therapeutic environment on an acute care mental health unit? select all that apply. one, some, or all responses may be correct - reorienting clients to the rules of the unit whenever necessary - providing a posted schedule of unit activities - monitoring each client for the potential of aggressive behavior - assuring clients that they will have unlimited access to their phones - encouraging the clients to take an active role in planning the unit's activities

- reorienting clients to the rules of the unit whenever necessary - providing a posted schedule of unit activities - monitoring each client for the potential of aggressive behavior - encouraging the clients to take an active role in planning the unit's activities (60% students answered correctly) (rationale: safety, structure, balance, and limit setting are elements that the nurse addresses when providing a therapeutic milieu. privileges cannot be assured because they are earned and often are factors affected by the clients' needs/ behaviors)

a female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. the RN also determines that the client is homeless and is exhibiting suspiciousness. the client's plan of care should include what priority problem? - acute confusion - ineffective community coping - disturbed sensory perception - self-care deficit

acute confusion

a male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (risperdal). when the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. what action should the RN take? - medicate the client with the prescribed antipsychotic thioridazine (mellaril) - offer the client a prescribed physical therapy hot pack for muscle spasms - direct client to occupational therapy to distract him from somatic complaints - administer the prescribed anticholinergic benztropine (Cogentin) for dystonia

administer the prescribed anticholinergic benztropine (Cogentin) for dystonia

following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is belligerent when another RN is assigned. what action should the charge RN implement? - reassure the client that his request will be met whenever possible - advise the client that assignments are not based on the client's request - ask the client to explain why he constantly requests the RN - encourage the client to verbalize his feelings about the RN

advise the client that assignments are not based on the client's request

when preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? - if your partner is abusing you, I need to ask these questions - state law mandates that I ask if you are a victim of domestic violence - the HCP provider needs to know if you are experiencing any domestic abuse - all clients are screened for domestic abuse because it is common in our society

all clients are screened for domestic abuse because it is common in our society

while setting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. the two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques? - discuss the client's feeling when he responds - allow the client to identify the way he interacts - initiate a non-threatening conversation with the client - dialog about the ineffectiveness of his interaction

allow the client to identify the way he interacts

while sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. the two trade places, and the RN demonstrates the client's behaviors. what is the main goal of this therapeutic technique? - initiate a non-threatening conversation with the client - dialog about the ineffectiveness of his interactions - allow the client to identify the way he interacts - discuss the client's feelings when he responds

allow the client to identify the way he interacts

a homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. which action is most important for the RN to implement within the first 24 hours after treatment is initiated? - allow the client to rest and sleep - ensure client attend groups addressing coping skills for dealing with depression - begin planning for the clients discharge - encourage verbalization of feelings

allow the client to rest and sleep

a woman is brought to the psychiatric clinic by her husband. he reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. which nursing problem applies to this client's behavior? - ineffective protection to guard self from internal or external threats - risk for injury related to inability to communicate - risk prone health behavior related to self-esteem assault - anxiety related to real or perceived threat to physical integrity

anxiety related to real or perceived threat to physical integrity

a 65-year-old female client complains to the nurse that recently she has been hearing voices. what question should the nurse ask this client first? - do you have problems with hallucinations - are you ever alone when you hear the voices? - has anyone in your family had hearing problems? - do you see things that others cannot see?

are you ever alone when you hear the voices?

the mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. how should the RN respond to the mother? - ask the mother if she has ever thought about harming herself or her child - reassure the mother that her child will achieve some growth and development milestones - determine if the mother has other children who do not have developmental disabilities - encourage the mother to write thoughts and feelings in journal

ask the mother if she has ever thought about harming herself or her child

the RN on the day shift receive report about a client with depression who was in bed most of the weekend. the RN walks into the client's room in the morning and finds the client in bed. what intervention is best for the RN to implement? - monitor the client's appetite and pattern of sleep - assess the client's feelings about the hospital stay - assist the client to get out of bed and involved in an activity - explain that staff will check on the client every 30 minute

assist the client to get out of bed and involved in an activity

a young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. she is afebrile, denies chills, and all laboratory findings are within normal limits. during the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. which response is best for the RN to provide? - unless your sister has a medical education, ignore her comments - I can hear that your sister comments are over-whelming you - do you think it's possible that you might be a hypochondriac? - besides your sister's comments, what in your life is troubling you?

besides your sister's comments, what in your life is troubling you?

a male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. when the nurse asks the teen to identify his reason for the assault, he replies, "because he made me mad!" which goal is best for the nurse to include in the client's plan of care? the client will - outline methods for managing anger - control impulsive actions toward self and others - verbalize feelings when anger occurs - recognize consequences for behaviors exhibited

control impulsive actions toward self and others

which action would the nurse take for an adolescent who has been admitted to the psychiatric hospital with a diagnosis of anorexia nervosa? - schedule an endocrinology consult because of amenorrhea - confront those behaviors that reflect an inflated self importance - arrange for psychotherapy sessions to help develop a desire to accommodate others - develop a contact to achieve a weekly weight gain, with consequences for non achievement

develop a contact to achieve a weekly weight gain, with consequences for non achievement (57% students answered correctly) (rationale: treatment usually includes a contract for weight gain, signed by the client, whereby privileges are revoked if the weight is not gained - consequences for nonachievement;- the diet and the amount of food eaten are not the focus of care)

a client who is taking clozapine calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and high fever. which instruction will the nurse give the client? - stay in bed, drink fluids, take a dose of aspirin, and ask the primary health care provider to reduce the dosage of clozapine - discontinue the medication immediately and see the primary health care provider as soon as an appointment becomes available - continue the medication, drink fluids, take aspirin, and see the primary health care provider in a few days if the symptoms do not improve - discontinue the medication and, if the primary health care provider is unavailable today, go to the emergency department for evaluation

discontinue the medication and, if the primary health care provider is unavailable today, go to the emergency department for evaluation (68% students answered correctly) (rationale: symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and may cause death)

on admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. it is best for the nurse to encourage this client to become involved in which activity? - clean the unit kitchen cabinets - participate in a group quilting project - watch television in the activity room - bake a cake for a resident's birthday

participate in a group quilting project

which assessment finding would the nurse observe in a client who has been found to have an antisocial personality disorder? - pays great attention to detail and demonstrates a high level of anxiety - has scars from self-mutilation and a history of many negative relationships - displays charm, has an above-average intelligence, and tends to manipulate others - demonstrates suspiciousness, avoids eye contact, and engages in limited conversation

displays charm, has an above-average intelligence, and tends to manipulate others (39% students answered correctly) (rationale: a client with an antisocial personality disorder is charming on first contact, but this charm is a manipulative ploy. these clients usually are bright and use their intelligence for self-gain)

which response would the nurse make to a client who has been on a psychiatric unit for several weeks and continually talks about delusional topics? - asking the client to explain the delusion - allowing the client to maintain the delusion - encouraging the client to focus on reality issues - explaining to the client why the thoughts are not true

encouraging the client to focus on reality issues (52% students answered correctly) (rationale: because the client has been on the unit for several weeks, the nurse would encourage this, which helps decrease delusional and hallucinatory activity by reducing feelings of isolation and competition for sensory awareness)

a client tells the RN that he has an IQ of 400+ and is a genius and an inventor. he also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. what is the priority nursing problem for admission to the psychiatric unit? - ineffective sexual patterns - impaired environmental interpretation - disturbed sensory perception - compromised family coping

ineffective sexual patterns

the RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. which intervention should the Rn implement the evening before the scheduled ECT? - hold all bedtime medications - keep the client NPO after mid-night - implement elopement precautions - give the client an enema at bedtime

keep the client NPO after mid-night

a female client requests that her husband be allowed to stay in the room during the admission assessment. when interviewing the client, the RN notes a discrepancy between the client's verbal and nonverbal communication. what action does the RN take? - pay close attention and document the nonverbal messages - ask the client's husband to interpret the discrepancy - ignore the nonverbal behavior and focus on the client's verbal messages - integrate the verbal and nonverbal messages and interpret them as one

pay close attention and document the nonverbal messages

which action would the nurse take to minimize psychological stress in an anxious client who has been admitted to the psychiatric unit? - explain in detail the therapies being used - learn what is of particular importance to the client - advise the client that the nurse is in charge of the client's situation - avoid the discussion of any areas that may be emotionally challenged

learn what is of particular importance to the client (62% students answered correctly) (rationale: providing support, understanding, and acceptance of feelings that the client is experiencing is essential for reducing stress. explaining in detail the therapies being used most likely will have the effect of increasing the client's anxiety. advising the client that the nurse is in charge of the client's situation is an authoritarian approach. the psychiatric unit provides the client with a safe, accepting environment in which to face problems and discuss emotionally charged areas)

which intervention would the nurse perform for an extremely agitated client who begins to pace around the mental health dayroom? - locking the client in their room to limit external stimuli - letting the client pace in the hall away from other clients - getting the client involved in a card game to distract the client's thoughts - encouraging the client to work with another client on a unit task

letting the client pace in the hall away from other clients (60% students answered correctly) (rationale: allows client to work off energy without upsetting other clients)

a 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. the nurse understands that a client's delusions are most likely related to his - early childhood experiences involving authority issues - anger about being hospitalized - low self-esteem - phobic fear of food

low self-esteem

which nursing action would be priorityfor a 2-year-old boy's mother who attempts suicide and is admitted to the mental health unit? - supporting parental skills - ensuring the child's safety - maintaining constant observation of the client - encouraging the client's participation in activities

maintaining constant observation of the client (47% students answered correctly) (rationale: ascertaining the child's safety is important but not the priority for the nurse caring for the suicidal client)

which nursing objective would be essential in the therapeutic psychiatric environment for a confused client? - assisting the client to relate to others - making the hospital atmosphere more homelike - helping the client become accepted in a controlled setting - maintaining the highest level of safe, independent function

maintaining the highest level of safe, independent function (80% students answered correctly) (rationale: the essential nursing objective is to maintain the highest level of safe, independent function)

which term describes the expected outcomes for a client who is admitted for a recurrent mental health problem? - long term goals - variances of care - clinical pathways - measurable objectives

measurable objectives (54% students answered correctly) (rationale: expected outcomes are measurable and realistic and reflect desirable projected responses to therapeutic interventions that consider the client's present and potential capabilities)

while caring for an older client, the RN observes multiple bruises in the client's legs, arms, back, and gluteal areas. the RN suspects elder abuse. what action should the RN take? - report family conversations and anger towards the client when visiting - ask the client specific questions about someone causing the bruising - question the family members and caregiver how the bruising occurred - measure and document size, shape and color of the bruised areas

measure and document size, shape and color of the bruised areas

the Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. the RN only has 15 minutes to talk to the client. to develop treatment plan for this client, which assessment is most important for the RN to obtain? - motivation of treatment - history of substance use - medication compliance - mental status examination

mental status examination

the RN is performing intake interviews at a psychiatric clinic. a female client with a known history of drug abuse reports that she had a heart attack four years ago. use of which substance places the client at highest risk for myocardial infarction? - benzodiazepine - alcohol - methamphetamine - marijuana

methamphetamine

a client is admitted to the mental health unit reports shortness of breath and dizziness. the client tells the RN, "I feel like I'm going to die". which nursing problem should the RN include in this client's plan of care? - mood disturbance - moderate anxiety - altered thoughts - social isolation

moderate anxiety

a male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. he has a bruised, swollen tongue and is confused. in developing a plan of care, which action should the RN include to ensure the client is physiologically stable? - encourage oral fluids - monitor vital signs - keep the room dark - apply ice to his tongue

monitor vital signs

a male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. which action is best for the RN to take? - report the behavior to the next shift. - offer to play a game of cards with the client - document the behavior in the chart - plan to talk with the client the next day

offer to play a game of cards with the client

the RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. which approach should the RN use when changing this client's dressing? - provide detailed thorough explanations when cleansing wound - perform the dressing change in a non-judgmental manner - ask in a non-threatening manner why the client cut own abdomen - request another staff member assist with the dressing change

perform the dressing change in a non-judgmental manner

a client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. which intervention during the first 6 hours following admission should the nurse identify as the priority? - place in a side-lying position with head of bed elevated - administer disulfram (atabuse ) immediately - give lorezapam (ativan)PRN for signs of withdrawal - provide thiamine and folate supplements as prescribed

place in a side-lying position with head of bed elevated

for which behavior would the nurse incur liability in handling an inpatient psychiatric client who is laughing loudly and making inappropriate comments to other clients and staff? - reporting the client's behavior to the treatment team - checking the client prescriptions for an as-needed medication to help calm the client - placing the client in seclusion only until the client stops verbally attacking clients and staff - bringing the client to a quiet area and encouraging a discussion of thoughts and behavior

placing the client in seclusion only until the client stops verbally attacking clients and staff (48% students answered correctly) (rationale: it is unlawful to place a client in seclusion simply because they are annoying or bothersome to others)

a client is receiving benztropine mesylate (cogentin) for drug-induced extrapyramidal syndrome (EPS). which finding indicates that the RN should further evaluate the client? - decreased bowel movements - presence of a dry mouth - decreasing hand tremors - increased mouth movements

presence of a dry mouth

which nursing intervention would be essential for a client with antisocial personality disorder who is admitted to the mental health hospital? - encouraging interactions with others - presenting a united, consistent staff approach - assuming a nurturing, forgiving tone in disputes - using seclusion when manipulative behaviors are exhibited

presenting a united, consistent staff approach (69% students answered correctly) (rationale: clients with antisocial personality disorder are experts in manipulation and may attempt to divide staff)

a child is brought to the emergency room with a broken arm. because of other injuries, the nurse suspects the child may be a victim of abuse. when the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "i won't leave my son! don't you touch him! you'll hurt my child!" what is the best interpretation of the mother's statements? the mother is - regressing to an earlier behavior pattern - sublimating her anger - projecting her feelings onto the nurse - suppressing her fear

projecting her feelings onto the nurse

a male client approaches the RN with an angry expression on his face and raises his voice, saying "my roommate is the most selfish, self-centered, angry person I have ever met. if he loses his temper one more time with me, I am going to punch him out!" the RN recognizes that the client is using which defense mechanism? - denial - projection - rationalization - splitting

projection

which would be the nurse's priority when caring for a schizophrenic client exhibiting signs of impaired judgment, paranoia, and agitation? - protecting other clients - placing the client in seclusion - giving an antipsychotic medication - talking to the client in a calm manner

protecting other clients (rationale: when managing the care of a client with schizophrenia who is agitated and paranoid, the nursing priority would be to ensure the safety of the other clients. once clients are safe, the nurse would talk to the client in a calm manner to attempt to de-escalate the situation)

which intervention would the nurse include in the plan of care for an adolescent with anorexia nervosa who is admitted to the psychiatric unit? - limit opportunities for decision making - provide supervision during and after mealtimes - arrange for a physical exercise program with time to complete it - request that parents keep their visits to a minimum in early treatment

provide supervision during and after mealtimes (93% students answered correctly) (rationale: clients with anorexia often throw out or hide food, or purge after eating)

a client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. the client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. what intervention should the RN implement? - assure the client that all food served in the hospital is safe to eat - tell the client that irrational thinking is a symptom of schizophrenia - obtain an order for a tube feeding for the client - provide the client with food in unopened containers

provide the client with food in unopened containers

a client in the mental health unit is walking swiftly around the room and rubbing his hands together. which term describes the behavior? - tardive dyskinesia - withdrawal syndrome - psychomotor agitation - psychophysiological insomnia

psychomotor agitation (89% students answered correctly) (rationale: is constant motion such as pacing, hand wringing, nail biting, and other types of energetic body movements)

after receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. what action should the RN take? - refer the student to a psychiatrist for further discussion - recommend assignment to the receptionist's office - suggest that student work in the athletic department - determine the parent's opinion of the work assignment

recommend assignment to the receptionist's office

the RN leading a group session of adolescent clients gives the members a handout about anger management. one of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. what nursing action is best for the RN to take? - explore the client's feelings about his pets and home life - encourage his peers to help involve him in the activity - give the client permission to leave and return in 10 minutes - redirect him by encouraging him to read from the handout

redirect him by encouraging him to read from the handout

a RN is preparing the physical environment to interview a new client for admission to the mental health unit. which environmental setting facilitates the best outcome of the interview? - dim the lights in the room to help the patient feel calm - sit within two feet of the client to enhance level of safety and security - reduce the noise level in the room by turning off the television and radio - position table between the client and the RN for extra personal space

reduce the noise level in the room by turning off the television and radio

the nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. which interventions should be included when providing a therapeutic milieu in an inpatient setting? - opportunities to contribute to one's treatment plan - one on one dialogue sessions with the therapist - regularly scheduled unit activities for peer interaction - home visits to reintergrate into the family

regularly scheduled unit activities for peer interaction

the nurse is caring for a group of clients on the psychiatric unit. which clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? - continuous involuntary movement of the tongue and jaw - extremely high BP with headache and flushing - blurred vision, urine retention, dry mouth, and constipation - restlessness, tachycardia, fever, diarrhea, and altered mental status

restlessness, tachycardia, fever, diarrhea, and altered mental status (79% students answered correctly) (rationale: these are related to serotonin syndrome. A is tardive dyskinesia, B is a possible hypertensive crisis from intake of tyramine containing foods by a client receiving a MAOI, and C are anticholinergic effects from tricyclic antidepressants and some antipsychotics)

a female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. picking herself up, she begins to toss chairs aside, looking for a red one to sit in. when another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." which nursing problem best supports these observations? - deficient diversional activity related to excess energy level - risk for other related violence related to disruptive behavior - risk for activity intolerance related to hyperactivity - disturbed personal identity related to grandiosity

risk for other related violence related to disruptive behavior

the nurse providing care for a client admitted to the psychiatric unit with a bipolar disorder strives to provide adequate nutrition during the client's manic phase. which statement explains the challenge of meeting this client's nutritional needs? - the client is too depressed to eat - the client lacks the energy to eat - the client is too busy keeping active to eat - the client is on a restricted diet, limiting cheese - the client is unable to eat favorite foods

the client is too busy keeping active to eat (81% students answered correctly) (rationale: the client is too busy keeping active during the manic part of a bipolar disorder. this stage's characteristics include elation, activity, restlessness, and increased energy. although the client may be using more calories than usual during this period, food is not a priority, and the client will not spend the time to eat. The nurse would need to suggest finger foods and high-calorie snacks)

the nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. which parental behavior provides the greatest validation for such suspicions? - the parents' explanation of how the burns occurred is different from the child's explanation of how they occurred - the parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem - the parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation - the parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn

the parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn

which reason explains why so many psychiatric clients are given benztropine or trihexyphenidyl in conjunction with phenothiazine-derivative neuroleptic medications? - they reduce postural hypotension - they potentiate the effects of the neuroleptic medication - they combat the extrapyramidal side effects of the neuroleptic medication - they ameliorate the depression that may accompany schizophrenia

they combat the extrapyramidal side effects of the neuroleptic medication (84% students answered correctly) (rationale: benztropine and trihexyphenidyl control the extrapyramidal (parkinsonian) manifestations associated with the neuroleptics and are classified as antiparkinsonian medications)

which statement best describes the goal of psychiatric nursing? - to help people with existing or potential mental health problems - to act therapeutically with people who have diagnosed mental disorders - to ensure clients' legal and ethical rights by serving as a client advocate - to focus interpersonal skills on people with physical or emotional problems

to help people with existing or potential mental health problems (59% students answered correctly) (rationale: primary, secondary, and tertiary interventions to prevent mental health problems and to promote or restore emotional equilibrium constitute important aspects of the role of the psychiatric nurse. acting in a therapeutic manner with people with diagnosed mental disorders is only a part of the role of the psychiatric nurse)

after discharge from an inpatient mental health facility, which goal is the primary purpose for referring the client to a mental health daycare center? - to offer an opportunity to improve social skills - to provide a place to go for a few hours daily - to maintain gains achieved during hospitalization - to avoid direct confrontation with the community

to maintain gains achieved during hospitalization (77% students answered correctly) (rationale: provides a therapeutic setting for a few hours each day during the transitional stage between hospital and total discharge)

a client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client's rooms. the RN decides that the client needs constant observation based on which of these assessment findings? - wanders into the clients rooms - refuses antipsychotic medications - talks with nonsensical words - disrupts group activities

wanders into the clients rooms

a male hospital employee is pushed out the way by a female employee because of an oncoming gurney. the pushed employee becomes very angry and swings at the female employee. both employees are referred for counseling with the staff psychiatric RN. which factor in the pushed employee's history is most related to the reaction that occurred? - is worried about losing his job to a woman - tortured animals as a child - was physically abused by his mother - hates to be touched by anyone

was physically abused by his mother

a male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (zypexa), because of the side effects he experienced when he took the drug for a year. which experience is most likely related to taking olanzapine? - weight gain of 75 lbs - thoughts of wanting to hurt himself - frequent days with diarrhea - alerted liver function test

weight gain of 75 lbs