Mental Health

A nurse is assisting with the development of an in-service about conversion disorder in adolescents. Which of the following information should the nurse include in the teaching?

"Conversion disorder can be caused by posttraumatic stress disorder."

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse include?

"Expect that your mood might take one to three weeks to begin improving."

A nurse is reinforcing teaching with the parents of a school-age child who has a new prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include?

"Give your child's medication dose in the morning."

A nurse is assisting with the admission of an older adult who is confused. Which of the following statements by the client's partner indicates that the client may be experiencing delirium?

"Her behavior changed so quickly, I wasn't sure what was happening."

A nurse is caring for a client who is threatening to commit suicide. Which of the following questions should the nurse ask?

"How will you carry out your plan?"

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states, "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

"I expect you to speak to me in a civil tone of voice."

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

"I'll just sit here with you for a few minutes then."

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

"It seems like you are feeling helpless about this behavior."

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

"It sounds like you're having a difficult time."

A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the medicine is supposed to do. Which of the following responses should the nurse make?

"This medication will clear your thinking."

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

"What are the voices telling you to do?"

A nurse is reinforcing teaching with a client who has major depressive disorder and a new prescription for fluoxetine. Which of the following statements should the nurse make to the client?

"You could experience withdrawal manifestations if you stop taking fluoxetine abruptly."

A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?

"You should change positions slowly while taking this medication."

A nurse is reinforcing teaching with a client who is to begin taking a monoamine oxidase inhibitor (MAOI) in addition to a selective serotonin reuptake inhibitor (SSRI). Which of the following statements should the nurse include in the teaching?

"You will need to be off the SSRI for at least two weeks before starting the MAOI."

A client who is depressed and has attempted suicide tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

"You've been feeling that your life has no meaning."

A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the provider see first?

A client taking clozapine who has a sore throat and mild fever.

A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide?

A client who has an obsessive-compulsive disorder and takes fluoxetine

A nurse in an acute care mental health facility is caring for a hospitalized client who has agoraphobia. The nurse observes that the client is making progress when he is able to participate in which of the following activities?

A picnic in a local park

A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse includes which of the following? (Select all that apply.)

Ability to perform calculations ​Level of consciousness Presence of suicidal thoughts ​Level of orientation

A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take?

Acknowledge the feelings the client is experiencing regarding the delusion.

A nurse is collecting data from a client who is to begin taking alprazolam. Which of the following findings should the nurse identify is a contraindication to this medication?

Alcohol use disorder

A nurse is caring for a client who has anorexia nervosa and insists on exercising three times each day. Which of the following actions should the nurse take?

Allow the client to exercise once per day for a set amount of time.

A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Amenorrhea Altered body image Hypokalemia

A nurse is caring for a group of clients in an acute mental health facility. The nurse should recognize that which of the following clients has the legal right to refuse treatment?

An older adult client who was voluntarily admitted

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?

Assist the client in identifying his anxiety level.

A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

Assist the client to practice social interaction with peers during a community meeting.

A nurse is collecting data from a client who underwent a stressful event and is experiencing fight-or-flight syndrome. Which of the following findings should the nurse expect as an immediate response in the client?

Decreased gastrointestinal motility

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

Decreasing anxiety to a tolerable level.

A nurse is discussing group therapy with a client who has a depressive disorder. Which of the following benefits of group therapy should the nurse include? (Select all that apply.)

Decreasing feelings of isolation Gaining support and encouragement from other group members

A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Denial

A nurse is caring for a client who has paranoid schizophrenia and is taking quetiapine. The nurse should observe the client for which of the following adverse effects?

Drowsiness

A nurse is preparing to assist with the care of a client who is to undergo electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.)

Electroencephalogram (EEG) monitor Oxygen saturation monitor Electrocardiogram (ECG) monitor

A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which of the following is an appropriate intervention by the nurse?

Encourage the client to focus on reality-based issues.

A nurse is collecting data from a client who has hypomania. Which of the following findings should the nurse expect?

Euphoria

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

Grandiosity

A nurse in an acute care mental health facility is caring for a client who commits suicide. Which of the following is the priority intervention for staff following this incident?

Identifying cues in the client's behavior that might have warned staff that he was contemplating suicide.

A nurse is collecting data from a client who has agoraphobia. Which of the following prescriptions should the nurse anticipate the provider will prescribe?

Imipramine

A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

Increased anxiety

A nurse at a mental health facility is discussing antidepressant medications with a newly licensed nurse, comparing selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Which of the following information should the nurse include about TCAs?

Increased risk of cardiovascular adverse effects

A nurse is assisting in the planning of care for a client who has a personality disorder and demonstrates manipulative behavior. Which of the following interventions is appropriate to include in the plan of care?

Institute consequences for manipulative behavior.

A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?

Irritability

A nurse is reinforcing teaching with a group of adolescents regarding identifying behavioral indicators of depression. Which of the following manifestations should the nurse include? (Select all that apply.)

Irritability Decreased energy Isolation from peers

A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions indicates that the client is experiencing maladaptive grieving?

Leaving the child's room exactly as it was before the loss.

A nurse is assisting with the admission of a client who has bipolar disorder and is experiencing an acute depressive episode. Which of the following prescriptions should the nurse anticipate receiving from the provider?

Lithium carbonate

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

Muscle contractions of the neck Fidgeting behavior ​​Impaired gait

A nurse is contributing to the plan of care for a client who is newly admitted with severe depression. Which of the following actions should be added to the plan of care?

Offer the client frequent small snacks during waking hours.

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following is an appropriate food choice for this client?

Peanut butter sandwich

A nurse in a mental health facility is caring for a client who is readmitted for schizophrenia after 2 weeks following the previous discharge. The nurse notices that the client's appearance is unkempt, and the client is mumbling to himself constantly. Which of the following assessments is the nurse's priority?

Physical health needs.

A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

Planning to give his CD collection to his girlfriend

A nurse is collecting data from a client whose husband died during a hurricane one year ago. The client reports having nightmares about the hurricane, persistent thoughts of blaming herself for her husband's death, and has stopped participating in her usual activities. The nurse should identify that the client is experiencing which of the following disorders?

Posttraumatic stress disorder

A nurse is caring for a client who is exhibiting signs of serotonin syndrome. Which of the following is the nurse's priority intervention?

Preparing for artificial ventilation

A nurse is caring for a client who has depression and a new prescription for bupropion. The nurse should collect data from the client regarding which of the following contraindications for taking bupropion?

Recent head trauma

A nurse is caring for a client who washes her hands repeatedly and almost constantly. The nurse should recognize the client's actions as which of the following?

Relieving the client's anxiety

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions is the nurse's priority?

Remain with the client in a quiet area.

A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

Serve individual items that have sealed packaging.

A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

Set aside short, frequent times each day to spend with the client.

A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Set behavioral limits for the client.

A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Set limits on the amount of time the client talks about delusions.

A nurse is contributing to the plan of care for a newly-admitted client who has severe depressive disorder. Which of the following interventions should the nurse include in the plan?

Spend time with the client.

A nurse is reinforcing teaching with a client who is to start taking lithium carbonate. Which of the following dietary supplements should the nurse instruct the client to avoid?

St. John's Wort

A nurse in an acute care mental health facility is caring for a client who begins to have a panic attack. Which of the following actions should the nurse take first?

Stay with the client in a quiet place.

A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

Suicide risk

A nurse is caring for a client with has schizophrenia and is taking haloperidol. The nurse should monitor the client for which of the following adverse effects?

Tardive dyskinesia

A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?

The client has the right to refuse medication.

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

The client is easily startled by loud voices.

A nurse is caring for a client who has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following situations should the nurse administer the alprazolam?

The client reports his heart is beating out of his chest

A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?

Vomiting and diarrhea

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Walk with the client at a gradually slowing pace.

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Whether the client is a danger to herself or others.

A nurse is reviewing laboratory results for a client who is receiving lithium carbonate. The client's blood lithium level is 1.8 mEq/L. Which of the following actions should the nurse take?

Withhold the medication

​A nurse is teaching a newly licensed nurse about electroconvulsive therapy (ECT). Which of the following statements by the newly licensed nurse indicates understanding?

​"Informed consent should be obtained prior to ECT."

A nurse is reviewing the medical record of a client who has a new prescription for clozapine. Which of the following findings should the nurse identify as a contraindication for this medication?

​Bone marrow depression

​A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

​Increasing feelings of anger

A nurse is collecting data from a client who is receiving multiple antipsychotic medications. The client exhibits muscle rigidity, hyperpyrexia, and diaphoresis. The nurse should identify that the client may be experiencing which of the following adverse effects?

​Neuroleptic malignant syndrome

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

​Significant change in weight