Menatl Health Final
During an assessment, a client states the inability to have long-term relationships and fears being abandoned. Which question would the nurse ask to help identify the reason for the client's feelings?
"Did your parents consume alcohol when you were growing up?"
The mental health nurse assesses for the most common mental health disorder found in children when asking which question?
"Do you ever get scolded at school for not sitting still?
An adult client diagnosed with social phobia is being treated in the clinic. Which screening question should the nurse ask the client to assess for the possible comorbidity of attention-deficit/hyperactivity disorder (ADHD)?
"How often do you have difficulty getting things in order when you have to do a task that requires organization?"
The nurse is developing a plan of care for a school-age child with a psychiatric disorder. Which intervention(s) will the nurse initiate that will address the child's immediate needs? Select all that apply.
- Monitor the child for safety. - Promote self-esteem. - Provide emotional support to the child and parents.
An appropriate goal for a client newly admitted to the unit for alcohol withdrawal is what?
Verbalize feeling safe and comfortable.
Which statement indicates the caregiver's accurate knowledge about the needs of a parent at the onset of the moderate stage of dementia? - "I need to give my parent a bath at the same time every day." - "I need to postpone any vacations for 5 years." - "I need to spend time with my parent doing things we both enjoy." - "I need to stay with my parent 24 hours a day for supervision."
"I need to spend time with my parent doing things we both enjoy."
A client with a history of alcohol use disorder is participating in a 12-step Alcoholics Anonymous (AA) program. A nurse determines that the client is at step 2 based on what statement by the client?
"I realize that there is a higher power that can help me." Coming to believe that a power greater than oneself could help restore sanity reflects the second step of AA. Admitting to one's self and others about wrongdoings reflects step 5 of AA. Admitting powerlessness over alcohol is step 1. Making amends is part of step 9.
The nurse is teaching a client admitted with acute alcohol withdrawal about medications used to prevent complications during the withdrawal from alcohol. The nurse recognizes that teaching has been effective when the client makes which statement?
"I will be given a benzodiapine over several days as a substitution for alcohol."
The nurse is teaching a 12-year-old child with an intellectual disability about medications. Which action is essential? - Speak slowly and distinctly. - Teach the information to the parents only. - Use pictures rather than printed words. - Validate client's understanding of teaching.
- Validate client's understanding of teaching.
The nurse has provided education to the parent of a child diagnosed with attention-deficit/hyperactivity disorder (ADHD) being prescribed methylphenidate. Which statement made by the parent would indicate a need for further teaching?
"I will expect my child to not need as much sleep on this medication."
Which statement by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse? - "I will remind Mother of things she has forgotten." - "I will keep Mother busy with favorite activities as long as she can participate." - "I will try to find new and different things to do every day." - "I will encourage Mother to talk about her friends and family."
"I will try to find new and different things to do every day."
A nurse is performing an assessment of a client with delirium after a prescribed dose of haloperidol. Which explanation does the nurse give to the client after being asked why they are taking it?
"In order to decrease your agitation and hallucinations."
The nurse provides care to a child whose parents recently separated and are planning to divorce. The child's parents ask the nurse how they can help their child deal with the situation. Which response by the nurse is appropriate?
"It is important that you help your child by not speaking negatively about the other."
A nurse is assessing a child who is suspected of having attention deficit hyperactivity disorder (ADHD). The parents ask about what actions the child may display. What statement(s) would the nurse provide? Select all that apply.
"The child is restless and can't sit still." "There is difficulty completing a task regardless of how simple." "The child has risk-taking behavior."
The nurse is mentoring a novice nurse in an inpatient Alzheimer disease unit. Which statement by the novice nurse requires additional teaching?
"The client with dementia will have reduced consciousness." Delirium often has a rapid onset, whereas Alzheimer disease progresses slowly. Also, reduced consciousness is a hallmark symptom of delirium, not dementia.
The nurse has been teaching a caregiver about donepezil (Aricept). The nurse knows that teaching has been effective when the caregiver makes which statement? - "Let's hope this medication will stop the Alzheimer's disease from progressing any further." - "It is important to take this medication on an empty stomach." - "I'll be eager to see if this medication makes any improvement in concentration." - "This medication will slow the progress of Alzheimer's disease temporarily."
"This medication will slow the progress of Alzheimer's disease temporarily."
The family of a client admitted for substance use disorder is being taught about enabling behaviors. Which statement(s) by the family demonstrates their understanding of the information provided by the nurse? Select all that apply.
"We can no longer make excuses or lie for them." "We will have to be more assertive and less passive." "We are not responsible for their money failures."
After educating the parents of a child diagnosed with attention deficit hyperactivity disorder (ADHD) on the disorder and its treatment, the nurse determines that the education has been effective when the parents make which statement?
"We need to remember that our child is not a bad kid but just has difficulty with impulse control and attention."
Which statement would indicate that medication teaching for the parents of a 6-year-old child with attention deficit hyperactivity disorder (ADHD) has been effective?
"We'll be sure to record the child's weight on a weekly basis."
A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic?
"You're in the hospital. You did not drink for several days, but you're getting better now."
A nurse is speaking to the parents of a child with attention deficit hyperactivity disorder (ADHD). The parents ask the nurse about the reason for the child's underachievement in academics. What explanation given by the nurse is most appropriate?
"Your child has trouble following the teacher's directions."
A nurse is working with an adolescent client who is scheduled for psychological evaluation. What type of nursing action(s) would best serve to determine the client's self-concept? Select all that apply.
- Ask the client to write a list of defining character traits. - Suggest to the client to make a drawing of oneself. - Find out what is of interest to the client and engage in conversation.
The nurse is assessing an adult client with ADHD. The nurse expects which to be present? - Difficulty remembering appointments - Falling asleep at work - Problems getting started on a project - Lack of motivation to do tasks
- Difficulty remembering appointments
Teaching for methylphenidate (Ritalin) should include which information? - Give the medication after meals. - Give the medication when the child becomes overactive. - Increase the child's fluid intake when they are taking the medication. - Check the child's temperature daily.
- Give the medication after meals.
The nurse recognizes which as a common behavioral sign of autism? - Clinging behavior toward parents - Creative imaginative play with peers - Early language development - Indifference to being hugged or held
- Indifference to being hugged or held
A teaching plan for the parents of a child with ADHD should include allowing as much time as needed to complete any task. - allowing the child to decide when to do homework. - giving instructions in short simple steps. - keeping track of positive comments that the child is given. - providing a reward system for the completion of daily tasks. - spending time at the end of the day reviewing the child's behavior.
- keeping track of positive comments that the child is given. - providing a reward system for the completion of daily tasks. - spending time at the end of the day reviewing the child's behavior.
The nurse would expect to see all the following symptoms in a child with ADHD, except - distractibility and forgetfulness. - excessive running, climbing, and fidgeting. - moody, sullen, and pouting behavior. - interrupting others and inability to take turns
- moody, sullen, and pouting behavior.
In a person who abuses alcohol or is a chronic drinker, alcohol withdrawal syndrome usually begins within which time frame from abrupt discontinuation or an attempt to decrease consumption?
12 hours
A client can expect symptoms of alcohol withdrawal to begin how many hours after the last drink?
8
Chapter 22: Neurodevelopment
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The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?
A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
After teaching a group of nursing students about delirium, the instructor determines a need for additional teaching when the students identify which as a primary goal of nursing care?
Achievement of self-esteem needs
Which of the following interventions is most appropriate in helping a client with early-stage dementia complete ADLs? - Allow enough time for the client to complete ADLs as independently as possible. - Provide the client with a written list of all the steps needed to complete ADLs. - Plan to provide step-by-step prompting to complete the ADLs. - Tell the client to finish ADLs before breakfast or the nursing assistant will do them.
Allow enough time for the client to complete ADLs as independently as possible.
The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client?
Alzheimer's disease
The parent of an 8-year-old client was concerned that the child may have an intellectual disability. The parent reports that the child has difficulty communicating. Which finding would confirm a diagnosis of intellectual disability?
An intelligence quotient (IQ) of 70 or below
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?
Aphasia
When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what?
Asking a family member to be present during the assessment
According to the psychodynamic theory regarding addiction, it is most important that the nurse assesses the client with an alcohol use disorder by considering what?
Asking the client to describe the client's childhood relationship with the client's parents
MAOI's (Please Take It Seriously) Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline (Emsam) transdermal patch - treatment of depression, some anxiety disorders, and Parkinson's disease.
Assist client in rising slowly from sitting position. Administer in a.m. Administer with food. Ensure adequate fluids. Perform essential teaching on the importance of low-tyramine diet. (cheese, red wine, sausage, processed meat, bananas, avocados) Side effects Drowsiness, dry mouth, overactivity, insomnia, nausea, anorexia, constipation, urinary retention, and orthostatic hypotension
While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?
CIWA-Ar
A nurse is assessing a child who had an episode of passing feces in the classroom. The child has no other disabilities. The nurse concludes that the child had intentional encopresis. Which other condition is the child likely to have?
Conduct disorder
Which term describes the use of socially unacceptable words, which are frequently obscene?
Coprolalia
A nurse is assessing an 8-year-old child. The child is unable to dress without assistance and is not able to manipulate toys, such as building blocks. The child stutters while talking. The difficulty with motor coordination was first noted after the child started to attend school, and it is not an aspect of a general underlying medical condition. What is the most likely diagnosis of the child?
Developmental coordination disorder
A client with late moderate-stage dementia has been admitted to a long-term care facility. Which nursing action will help the client maintain optimal cognitive function? - Discuss pictures of children and grandchildren with the client. - Do word games or crossword puzzles with the client. - Provide the client with a written list of daily activities. - Watch and discuss the evening news with the client.
Discuss pictures of children and grandchildren with the client.
The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest?
Distract the client with family photos and discuss the events pictured.
A nurse is assessing a child suspected of having autism spectrum disorder. Which behavior(s) assessed by the nurse correlates with this diagnosis? Select all that apply.
Echolalia Delayed language skills
Which aspect of managing a child with attention deficit hyperactivity disorder (ADHD) may often be overlooked in the treatment plan?
Effects on siblings
A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include?
Frequently provide reality orientation
A nurse is studying the brain images of children with attention deficit hyperactivity disorder (ADHD). In these images, the nurse would find abnormalities related to which area of the brain?
Frontal lobe
Donepezil (Aricept) 5-10 mg orally per day Monitor for nausea, diarrhea, and insomnia. Test stools periodically for gastrointestinal bleeding.
Galantamine (Reminyl, Razadyne, Nivalin) 16-32 mg orally per day divided into two doses Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope.
After teaching a group of nursing students about intellectual disability, the instructor determines that the teaching was successful when the students identify which as the most common etiology?
Genetic syndromes
A client with delirium is attempting to remove the IV tubing from his arm, saying to the nurse, "Get off me! Go away!" What is the client experiencing? - Delusions - Hallucinations - Illusions - Disorientation
Hallucinations
The nurse is assessing an adolescent client who was diagnosed with autism spectrum disorder as a child. On current assessment the nurse finds that the client's behavior has deteriorated. What may be the possible causes of this change? Select all that apply.
Hormonal changes Increased parental and peer pressure Inability to perform well in school
A client with dementia is having difficulty clearly communicating about physical needs. When teaching the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include?
Keep a record of bowel movements.
An adolescent client says the client has become bored with the video game that has been used as a reward for positive behavior. Which is the most effective intervention for this client?
Let the client choose another reward that would be more fun.
Which medication is used to prevent alcohol withdrawal symptoms?
Lorazepam (Ativan)
A client is experiencing severe alcohol withdrawal. Which would the nurse identify during the assessment that correlates with the withdrawal symptoms? Select all that apply.
Marked diaphoresis Auditory hallucinations Gross uncontrollable tremors
Which of these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist?
Memantine been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia
A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome?
Monitor amount of environmental stimulation and adjust as needed.
When teaching a client about memantine (Namenda), the nurse will include which information? - Lab tests to monitor the client's liver function are needed. - Namenda can cause elevated blood pressure. - Taking Namenda will improve the client's cognitive functioning. - The most common side effect of Namenda is gastrointestinal bleeding.
Namenda can cause elevated blood pressure.
Memantine (Namenda) 10-20 mg/day divided into two doses Monitor for hypertension, pain, headache, vomiting, constipation, and fatigue.
Namzaric (Memantine/Donepezil) 28 mg/10 mg orally per day Monitor for nausea, diarrhea, abdominal pain, loss of appetite, headache, and dizziness.
Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan for the client who is in withdrawal must include which nursing interventions?
Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered
A nurse is assessing a child with attention deficit hyperactivity disorder. Which assessment finding is the nurse likely to see in this child? Select all that apply.
Overactivity Impulsiveness
Serotonin Syndrome Serotonin syndrome occurs when there is an inadequate washout period between taking MAOIs and SSRIs or when MAOIs are combined with meperidine. Symptoms of serotonin syndrome include: - Change in mental state: confusion and agitation - Neuromuscular excitement: muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, and muscle paralysis - Autonomic abnormalities: hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis ( to much seratonin in a patients system)
Overdose of MAOI and Cyclic Antidepressants Both the cyclic compounds and MAOIs are potentially lethal when taken in overdose. To decrease this risk, depressed or impulsive clients who are taking any antidepressants in these two categories may need to have prescriptions and refills in limited amounts.
Which is an infection-related cause of delirium?
Pneumonia
Which is an infection-related cause of delirium?
Pneumonia sepsis, urinary tract infection, and meningitis. Lithium toxicity is a drug-related cause. Renal failure and sleep deprivation are physiologic causes.
The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention?
Provide the client with a tray, opening containers for the client.
A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate?
Providing emotional support and gentle reminders
A child with autistic spectrum disorder (ASD) is displaying temper tantrums. Which is the prioritygoal of treatment related to this issue?
Reduce behavioral symptoms.
Which can be identified as a hallmark symptom of dementia?
Short-term memory loss
The nurse is caring for a client with delirium. Which intervention(s) will help provide the best care for this client? Select all that apply.
Speak in simple, clear sentences. Support the client in following a regular routine. Assess the client's level of function at least daily. Allow adequate time for the client to comprehend and respond.
Which is a disturbance of the normal fluency and time patterning of speech?
Stuttering
The parents of a child with attention deficit hyperactivity disorder (ADHD) bring the child for a follow-up visit. During the visit, they tell the nurse that the child receives the first dose of methylphenidate at about 7:30 a.m. every morning before leaving for school. The teacher and school nurse have noticed a return in the child's overactivity and distractibility just before lunch. The child's second dose is scheduled for about 12 p.m. Which might the nurse suggest as a possible solution to control the child's symptoms a bit more effectively?
Switch to a longer-acting preparation.
The nurse is counseling a group of clients recovering from substance abuse about the nature of denial. Which intervention should the nurse teach the clients to use to help them gain insight into their denial?
Teach them to question why they feel threatened.
A nurse is working with a child undergoing behavioral modification therapy for attention deficit hyperactivity disorder (ADHD). The nurse finds that the child is thin. What could be the most likely reason for this observation?
The child cannot sit through meals.
A nurse is caring for a child with attention deficit hyperactivity disorder (ADHD). The child is given medication and behavioral modification therapy to treat the condition. Which outcome achieved within 3 days would indicate successful therapy?
The child is able to complete assignments or tasks with assistance.
The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion?
The client may echo whatever is heard.
The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation?
The client may have Korsakoff's syndrome. Korsakoff's syndrome usually is found in the 40- to 70-year-old client with alcoholism and a history of steady and progressive alcohol intake
The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as?
The client may have apraxia.
A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium?
The client removes the client's surgical bandage and begins picking at the sheets.
The client is 6-year-old who has been diagnosed with autism spectrum disorder. Which symptom would the client display?
The client spends time alone with little interest in making friends.
Major goals for the nursing care of clients with dementia should include what?
The client will be safe, be physiologically stable, and have infrequent episodes of agitation.
A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction?
The nurse wants to prevent increasing the client's confusion.
A client is in treatment for depression and alcohol abuse. The client is unwilling to confront substance abuse issues, stating the client uses alcohol to ease feelings of depression. The client's spouse reports that the spouse often has to care for the client when the client is hung over, calling in sick for the client and doing what the spouse can to help the client catch up with household or job responsibilities. The nurse diagnoses the client's family with dysfunctional family processes. The nurse and clients develop a plan of care. Which goal indicates an understanding of the family situation and the linkages between the diagnosis and the outcomes?
The spouse will refrain from the enabling the client's drinking behaviors.
After educating a group of nursing students on Alzheimer disease and appropriate nursing care, the instructor determines that the education was successful when the students identify which as the foundation for providing care to the client and family?
Therapeutic relationship
The nurse is assessing a client who is suspected of having an alcohol use disorder. The nurse asks about daily alcohol intake. The client replies, "The important point is that if I have 10 drinks, I don't get drunk." The nurse determines the client's response as what?
This is an indication of long-term use of alcohol for this client
An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the following day. Should the nurse be concerned about delirium?
Yes, because of the head injury and medication
Actions for clients with dementia that follow the psychosocial model of care include - asking the clients about the places where they were born. - correcting any misperceptions or delusion. - finding activities that engage the clients' attention. - introducing new topics of discussion at dinner. - processing behavioral problems to improve coping skills. - providing unrelated distractions when clients are agitated.
asking the clients about the places where they were born. finding activities that engage the clients' attention. providing unrelated distractions when clients are agitated.
A 2-year-old client is being assessed by the nurse during the annual well-visit check-up. Which assessment finding of the child would alert the nurse to follow-up with the parent to obtain more information?
becomes upset with minor changes in the routine
A psychiatric-mental health nurse is teaching a client about the physiological effects of long-term alcohol use. Which effect(s) may occur in the client with long-term alcohol use? Select all that apply.
cardiac myopathy Wernicke encephalopathy pancreatitis cirrhosis
When assessing a client with delirium, the nurse will expect to see - aphasia. - confusion. - impaired level of consciousness. - long-term memory impairment. - mood fluctuations. - rapid onset of symptoms.
confusion impaired level of consciousness mood fluctuations rapid onset of symptoms
The nurse cares for an older adult client with a neurocognitive disorder affecting executive function. Which assessment finding is most likely?
difficulty planning daily activities
The nurse is talking with a woman who is worried that her mother has Alzheimer's disease. The nurse knows that the first sign of dementia is - disorientation to person, place, or time. - memory loss that is more than ordinary forgetfulness. - inability to perform self-care tasks without assistance. - variable with different people.
memory loss that is more than ordinary forgetfulness.
A group of student nurses are reviewing diagnostic criteria for the clinical diagnosis of Alzheimer disease (AD). Which finding(s) indicates that a client may have AD? Select all that apply.
unable to identify a pen unable to verbally communicate inability to use a telephone