Lippincott and Saunders Psych questions
A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take INITIALLY?
Contact the client's healthcare provider
A client has been diagnosed with adjustment disorder with mixed anxiety and depression. What are the primary nursing diagnoses the nurse would associate with this type of adjustment disorder?
Impaired social interaction, the risk for situational low self-esteem
The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication?
In 2 to 3 weeks
The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information should the nurse incorporate in the discussion?
Increase fluids and bulk in the diet
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship?
Inquiring about and examining the client's feelings for an that may block adaptive coping.
A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which he lost both legs. The client states "I will never be able to work again or live a normal life". Which responses by the nurse would be considered therapeutic?
Losing both legs is hard to accept, how are you feeling now? The occupational therapist will teach the use of adaptive equipment to promote independence, I am here to help you. Let's devise a plan so you are working toward your goals
A nurse is caring for a client with agoraphobia. Which signs and symptoms would a nurse anticipate?
Panic attacks, inability to leave home
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level?
Toxic
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?
White blood cell count
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?
Writing
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?
A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?
A structured program of activities in which the client can participate
On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?
A willingness to participate in the planning of the care and treatment plan
A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose?
At the same time each evening
The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?
Battery, assault, false imprisonment
A nurse is caring for a client who has experienced frontal lobe damage in a car accident. Which psychosocial behaviors are indications of this damage?
Change in personality, overt sexual behavior, difficulty controlling temper, fewer spontaneous facial expressions
An 8-year-old child, diagnosed with obsessive-compulsive disorder (OCD), is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions?
Checking and rechecking that the television is turned off before going to school, repeatedly washing the hands, routinely climbing up and down a flight of stairs three times before leaving the house
A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly?
Client arrives at the clinic neat and appropriate in appearance.
A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication?
Crackers, tossed salad
The nurse is teaching a client diagnosed with a generalized anxiety disorder how to effectively cope with severe distress. Which interventions would the nurse use to promote effective coping with anxiety?
Discuss previous methods that were effective, encourage the client to limit to a mutually decided amount of time spent on worrying, help the client to establish a goal and develop a plan to meet the goal, teach the client how to label feelings and how to express them
A client says to the nurse "The federal guards were sent to kill me." Which is the BEST response by the nurse to the client's concern?
Do you feel afraid that people are trying to hunt you?
The nurse documents the following note in the medical record, "The patient has bruising on the upper arms in the shape of finger marks. Bruising in various degrees of resolution is noted on the lower back and abdomen. When the patient is asked about the marks the patient states I fell down the steps". Which communication is BEST to determine if domestic abuse is occurring?
Do you feel safe in your living situation?
A client, diagnosed with Alzheimer's disease, is a new resident in a long-term care facility. The client has difficulty finding their room and is seen wandering into the room of others. When discussing the situation at a multidisciplinary conference, which client-centered actions would the nurse suggest?
Ensure that the client has prescribed hearing aids and glasses on throughout the day, place a box with familiar personal items outside the client's door for visual recognition, assign the client to a room close to the nursing station for closer monitoring, provide verbal cueing as to where the client's room is located
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
Escort the client to their room, with the assistance of other staff
A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?
Frequent hand washing with hot, soapy water
The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of this medication?
Gastrointestinal dysfunctions
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse "I'm finally cured". Based on the client's behavior and statement, which intervention should the nurse include in the plan?
Increasing the level of suicide precautions
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach?
Milieu therapy
When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?
Monitor closely for harm to self or others
The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?
One-to-one suicide precautions
A client with a diagnosis of schizophrenia spectrum disorder is admitted to the inpatient unit after developing water intoxication. Once the client is medically stable and no longer exhibiting the behavior of seeking water, which nursing interventions are appropriate at this time?
Provide gum for the client, weigh the client every day, monitor the client's intake and output, and maintain a structured environment
The nurse in the ER is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors?
Reactions to a devastating event
A nurse is monitoring a client who appears to be hallucinating. The client is gesturing at a figure on the television and appears agitated with a speech containing paranoid content. Which nursing interventions are appropriate at this time?
Reassure the client that there is no danger, acknowledge the presence of the hallucinations, and give simple commands in a calm voice.
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client?
Restating, active listening, maintaining neutral responses, providing acknowledgment and feedback
A nurse is explaining client rights for psychiatric patients to a patient who has voluntarily sought admission to an inpatient psychiatric facility. Which rights would the nurse include in the discussion?
Right to refuse treatment, right to a written treatment plan, right to confidentiality, right to personal mail
A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication?
Seizure activity
The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication?
Tardive dyskinesia
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
The adolescent gives away a DVD and a cherished autographed picture of a performer
While assessing a client diagnosed with impulse control disorder, the nurse observes the client's violent, aggressive, and assaultive behavior when having to wait for a lunch tray to be delivered from the dietary department. Which history and assessment findings documented in the medical record is the nurse also likely to find?
The client functions well in other areas of life, the degree of aggressiveness is out of proportion to the stressor, the client has a history of parental alcoholism and a chaotic, abusive family life
The nurse is caring for a patient with severe depression. In which conditions would the nurse anticipate the use of electroconvulsive therapy (ECT) as an option?
The patient cannot tolerate monoamine oxidase inhibitors (MAOIs), the patient has not responded to conventional and antidepressant medication therapy, the patient is having acute suicidal thoughts
The nurse is assessing a client who is a polysubstance abuser, with cocaine being one of the drugs most frequently used. Which physiological symptoms are suggestive of early (phase 1) cocaine intoxication?
Tremors, psychomotor agitation, cardiac arrhythmias, dilated pupils
A client, brought to the emergency department by the police, is found wandering the streets of town and appears to be disoriented. During initial contact by the nurse, the client begins to laugh inappropriately and states feeling dizzy. Which client behaviors suggest that the client is symptomatic for hugging aerosols?
Unsteady gait, impaired memory of where they had been, slurred speech during a conversation, hallucinations of spiders crawling on the bed
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse "I should get out of this bad situation". Which is the most helpful response by the nurse?
What do you find difficult about this situation?
The nurse is conducting an initial assessment of a client in a crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?
What leads you to seek help now?
The police arrive at the ER with a client who has lacerated both wrists. Which is the best initial nursing action?
Assess and treat the wound sites
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?
Avoid using a whisper voice in front of the client
A nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential when formulating an effective discharge plan?
Communication patterns, role expectations, current family stressors
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach?
Helping the client to examine dysfunctional thoughts and beliefs
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?
Identifying anxiety-producing situations
A nurse caring for a client diagnosed with persistent depressive disorder. Which defining characteristics are associated with this disorder?
Insomnia or hypersomnia, loss of interest in daily activities, appetite disturbance
A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred?
Rapid heartbeat or anxiety
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
When I have command hallucinations, I'll call a friend for help
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
You seem restless, tell me what is happening
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me". Which is the nurse's best response?
You sound very upset. Are you thinking of hurting yourself?
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?
You're feeling angry that your family continues to hope for you to be cured?
The nurse is caring for a client experiencing panic post fireworks display over the holiday weekend. The client routinely takes a prescribed dose of alprazolam 1.5 mg PO TID. An additional PRN dosage is also prescribed as 1.5 mg PO every 4 hours. The maximum daily dose is 8 mg. How many additional doses of the PRN medication might the client take safely?
2
When beginning a client on newly prescribed antipsychotic medications, which symptoms are commonly seen within the first few weeks of treatment?
Acute dystonic reactions, akathisia, neuroleptic malignant syndrome, orthostatic hypotension
A nurse is conducting a group session for children and adolescents who have been diagnosed with depression. Which behaviors would a nurse anticipate in this group?
Anxiety, irritability, somatic symptoms, suicidal thoughts
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
Ask the client about the amount of drug use and its effect
A healthcare provider prescribes haloperidol PO 1 mg TID. When assessing the client for extrapyramidal adverse effects, which nursing measures would be initiated?
Closely monitor vital signs, especially temperature, observe for increased pacing and restlessness, and provide the client with sugar-free hard candy
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior?
Communicate expected behaviors to the client, assist the client in identifying ways of setting limits on personal behaviors, follow through about the consequences of behavior in a nonpunitive manner, have the client state the consequences for behaving in ways that are viewed as unacceptable
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note?
Dental decay, loss of tooth enamel, electrolyte imbalances
During the nurse's shift in the ER, a nurse assesses a client who is suspected of being under the influence of amphetamines. Which symptoms are indicative of amphetamine use?
Diaphoresis, shallow respirations, tremors, dilated pupils
During the nurse's assessment of a 15-year-old client diagnosed with bulimia nervosa, the nurse evaluates for findings that accompany binge eating. Which are most applicable?
Guilt, dental caries, self-induced vomiting, normal weight
Which interventions are most appropriate for caring for a client in alcohol withdrawal?
Monitor vital signs, provide a safe environment, address hallucinations therapeutically, and provide reality orientation as appropriate
The nurse is caring for a mental health client who exhibits passive-aggressive behavior when interacting with the nursing staff. When reporting client behaviors to the next shift, which actions are consistent with this assessment?
The client agrees with the staff but then complains to others, the client feels angry about the group session so they scatter papers in the lunchroom
A nurse selects a priority nursing diagnosis of fear related to being embarrassed in the presence of others for a client who exhibits symptoms of social phobia. Which outcomes if met would demonstrate improvement in the client's symptoms?
The client manages fear in group situations, verbalizes feelings that occur in stressful situations, develops a plan for responding to stressful situations
The nurse should plan which goals of the termination stage of group development?
The group evaluates the experience, the group explores members' feelings about the group and the impending separation
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
Using open-ended questions and silence
In the emergency department, a patient reveals to the nurse a lethal plan for dying by suicide and agrees to voluntary admission to the psychiatric unit. Which information would the nurse discuss with the patient to answer the question "How long do I have to stay here?"
You may leave the hospital at any time unless you're suicidal or homicidal or unable to meet your basic needs, Let's talk more after the healthcare team has assessed you, Because you have stated that you want to hurt yourself, you must be safe before being discharged
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bedroom. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
A client undergoing diagnostic tests
A nurse is employed at an outpatient rehabilitation facility caring for clients withdrawing from opioids. When assessing clients who present for their counseling session, which findings are anticipated at this time?
Abdominal cramps, rhinorrhea, dilated pupils
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time?
Acknowledge the client's behavior, assist the client to an area that is quiet, and maintain a safe distance from the client
A nurse is working in the emergency room when a police officer walks in with a rape victim to be examined. If the nursing goal is to reduce patient anxiety, which interventions would be appropriate?
Admit the patient to the treatment area right away, Assure the patient of safety in the examination room, Allow a third party to be present if the patient requests it, Ask factual questions to determine the type of assault
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client which is the first step in this 12-step program?
Admitting to having a problem
A nurse is preparing discharge instructions for a client with resistant depression who was prescribed a new medication regimen that includes phenelzine, a monoamine oxidase inhibitor (MAOI). If the teaching was successful, what foods would the client state that they need to avoid?
Aged cheese, wine, salami
A client is prescribed sertraline, a selective serotonin reuptake inhibitor. Which adverse effects would the nurse review when creating a medication teaching plan?
Agitation, sleep disturbance, dry mouth
The nurse is leading a group session when the nurse notices that a member of the group is tearful and shaking. Which nursing actions would be therapeutic at this time?
Ask the client to share the emotions that the client is feeling, direct a staff member to assist the client and continue the group
A nurse is working with a schizophrenic client who suddenly begins experiencing auditory hallucinations. Which interactions are appropriate at this time?
Ask the client, What are you experiencing right now, encourage the client to relate the history of the hallucinations, tell the client, Id like to spend time with you to discuss your hallucinations. Is that ok with you, ask the client if they have recently taken any drugs or alcohol
The nurse is preparing the following medication for a client who has a long-term history of situation anxiety and is now experiencing a panic attack. Ativan (lorazepam) injection 2 mg per mL. When assessing the client 15 minutes after medication administration, the nurse notes the following symptoms. Which client symptoms is the MOST concern?
Ataxia
A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place the highest priority on teaching the client which point that directly relates to client safety?
Avoid drinking alcohol while taking this medication
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?
Avoidant
A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away". The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?
Call the nursing supervisor
A delusional client says to a nurse, "I am an alien from Mars," and insists that the nurse refers to them as such. The belief appears to be fixed and unchanging. Which nursing interventions would the nurse implement when working with this client?
Consistently use the client's name in interactions, and redirect the client with structured activities.
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?
Conversion disorder
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?
Evidence of the client's disturbed body image.
A hospitalized patient becomes angry and belligerent toward a nurse after speaking on the phone with their mother. The nurse learns that the mother cannot visit as expected because of her work. Which interventions will the nurse use to help the client deal with the displaced anger?
Explore the patient's unmet needs, Acknowledge the patient's behavior as inappropriate, Invite the patient to a quiet place to talk after they settle down, assist the patient in identifying alternate ways of approaching the problem
The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client?
Get up slowly when changing positions
A client who is taking antipsychotic medication to control schizophrenia asks the nurse to explain the causes of the disorder. The nurse knows that an overactive dopamine system in the brain is one of the leading causes of schizophrenia and tells the client that excessive dopamine activity is responsible for symptoms. Which symptoms is the nurse referring to?
Hallucinations, suspiciousness, delusional thinking
The nurse is meeting a patient in the mental health unit. When beginning a therapeutic relationship, which nursing actions are appropriate?
Help the patient explore different problem-solving techniques, encourage the practice of new coping skills
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
Hypertension, changes in level of consciousness, hallucinations
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the MOST APPROPRIATE nursing response?
I cannot discuss any client situation with you
A nurse is caring for a client displaying extreme mood swings with suicidal tendencies. A healthcare provider prescribes lithium and diagnoses the client with bipolar disorder. When teaching the client, which statements, verbalized by the client, indicate a good understanding of the teaching of medication management?
I need to watch for signs and symptoms of drug toxicity including blurred vision and ringing in the ears, I will need to consistently monitor blood levels, The therapeutic effect of the medication takes time to occur.
The nurse determines that the wife of an alcoholic client is benefiting from attending an AL-Anon group if the nurse hears the wife make which statement?
I no longer feel that I deserve the beatings my husband inflicts on me
A client in a mental health unit becomes increasingly agitated and barricades himself in a corner room holding another client hostage. Verbal exchanges indicate an escalation in client desperation. Which nursing actions would be taken at this time?
Identify one nurse to interact with the client, direct other clients away from the area, discreetly notify security to assist, identify with the client's perspective and reason for agitation
After interviewing a client diagnosed with recurrent depression, a nurse determines the client's potential for death by suicide. Which factors listed below might contribute to the client's risk?
Impulsive behavior, overwhelming feelings of guilt, chronic debilitating illness, repression of anger
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
Interrupt the client and offer to take her for a walk
A male patient states feelings of sadness and is seeking suggestions for strategies to keep active after the loss of his spouse. Which activities might the nurse suggest to the patient?
Joining a golf league at a club, attending regular spiritual/church services, participating in a community charity event
A nurse is caring for a client recently diagnosed with cancer and experiencing moderate situational anxiety. Which interventions would the nurse include in the care plan?
Maintain a calm, nonthreatening environment, encourage the client to verbalize concerns regarding the diagnosis, and encourage the client to use deep breathing exercises and other relaxation techniques during periods of increased stress
A client is being seen in the clinic after returning from military service abroad. The nurse documents restlessness at night with nightmares leaving the veteran irritable and fatigued during the day. When discussing the possibility of posttraumatic stress disorder (PTSD), which statements about PTSD are accurate?
PTSD is characterized by nightmares and flashbacks, Hypervigilance is characteristic of clients with PTSD, Substance abuse is a common coping mechanism used by clients with PTSD, Psychotic episodes can occur in clients with PTSD, and clients with PTSD may complain of feeling empty inside
A nurse is caring for a patient who exhibits behaviors that test the nurse-patient relationship. When discussing this behavior at a multidisciplinary team conference, which behaviors would the nurse provide as examples of this behavior?
Placing the nurse in the role of parent, requesting personal information from the nurse, stating information to try to shock the nurse, violating the nurse's personal space
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?
Provide safety for the client and other clients on the unit
A nurse is caring for an anorexic client with a nursing diagnosis of imbalanced nutrition: less than body requirements related to dysfunctional eating patterns. Which interventions would be supportive for this client?
Provide small, frequent meals, monitor weight gain, allow the client to determine food choices from a menu, monitor the client during meals and for 1 hour afterward
A nurse is caring for a client with borderline personality disorder. Which interventions are appropriate for clients with this disorder?
Providing emotional consistency, exploring anger in appropriate ways, promoting gradual separation and individuation, ensuring the client's safety
The nurse is reviewing the process recording of a school-aged client describing how the client felt about their mother's recent death by suicide. Which nursing interventions are appropriate to add to the plan of care? Progress note, "My mother's suicide made me feel alone and sad. I did not want to come out of my room. I did not want to see anyone or talk about what happened. I just went to school every day and did what I needed to do."
Refer the client to a support group for kids who have lost parents, offer self by sitting with the client and allowing them to express their feelings, state "So you are feeling pretty sad", sit directly across from and focused on the child
A nurse is assessing a new client and notices clang associations in the speech pattern. From this assessment finding, the nurse begins to evaluate for the potential of which psychiatric conditions?
Schizophrenia, mania, cognitive disorders
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement?
Setting limits on the client's behavior
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?
Sit beside the client in silence with simple open-ended questions
The nurse is monitoring a client with schizophrenia who is prescribed clozapine. During the morning mental health team meeting, which symptoms indicating adverse effects of the medication would immediately be brought to the psychiatrist's attention?
Sore throat, fever, orthostatic hypotension
A client is prescribed chlordiazepoxide as needed to control the symptoms of alcohol withdrawal. Which symptoms may indicate the need for an additional dose of this medication?
Tachycardia, elevated blood pressure and temperature, tremors, increasing anxiety
What is the MOST APPROPRIATE nursing action to help manage a manic client who is monopolizing a group therapy session?
Thank the client for the input, but inform the client that others now need a chance to contribute
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?
The death of a loved one
A nurse has developed a therapeutic relationship with a patient who has an addiction disorder. Which patient behaviors would indicate that the therapeutic interaction is in the working phase?
The patient discusses how the addiction has contributed to family distress, The patient verbalizes difficulty identifying personal strengths, the patient discusses the financial problems related to addiction, The patient acknowledges the addiction's effects on their children
A nurse is assessing a client for a neurocognitive disorder such as dementia. What history findings would the nurse anticipate while talking with the client and family?
The progression of symptoms has been slow, the client admits to feelings of wanting to be alone, the family cannot determine when the symptoms first appeared, the client has been exhibiting basic personality changes, the client has great difficulty paying attention to others
A client is brought to the emergency department confused and agitated with aggressive behaviors toward the staff. The client is ordered haloperidol decanoate 100 mg IM STAT once the agitation escalated to include behaviors of screaming and throwing objects. In considering the client condition and behaviors exhibited, which location is BEST for the nurse to administer the IM injection?
The ventrogluteal (hip) region provides the most acceptable location for IM injection and the fastest route of absorption.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
Use an indirect light source and turn off the television
A nurse is developing a care plan for a client with acute mania. In what order would the behaviors progress from normal through mania.
Uses relevant, calm speech patterns, shows high productivity and competitive attitude in work and leisure activities, becomes easily irritated, demonstrates poor judgment and impulse control, has delusions of grandeur
The nurse visits a client at home. The client states "I haven't slept at all the last couple of nights". Which response by the nurse demonstrates therapeutic communication?
You're having difficulty sleeping?
A client with a diagnosis of depression who has attempted suicide says to the nurse "I should have died. I've always been a failure. Nothing ever goes with for me". Which response by the nurse demonstrates therapeutic communication?
You've been feeling like a failure for a while?
