Mental Health Assessment B

A nurse is collecting data from a client whose home was destroyed by a fire. Which of the following responses should the nurse make first? A) "Are you experiencing feelings of hopelessness?" B) "Is there someone I can call for you?" C) "It might be helpful for you to attend a support group." D) "Now is a good time for you to use relaxation breathing."

A) "Are you experiencing feelings of hopelessness?" When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe. The nurse should collect data about the client's feelings to determine if the client is having feelings of hopelessness or suicidal ideations.

A nurse is caring for a client who has a depressive disorder and declines electroconvulsive therapy (ECT) despite the provider's recommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client's decision? A) Autonomy B) Nonmaleficence C) Fidelity D) Justice

A) Autonomy The nurse is demonstrating the principle of autonomy by respecting and supporting the client's right to make decisions about her treatment.

A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse expect to administer? A) Naltrexone B) Bupropion C) Varenicline D) Phenobarbital

A) Naltrexone The nurse should expect to administer naltrexone, an opioid antagonist, to a client who is experiencing opioid withdrawal.

A nurse is reinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make? A) "You should exercise immediately prior to going to sleep." B) "You should listen to music when you feel stress." C) "Take a 1-hour nap every afternoon." D) "You should stop drinking caffeine immediately."

B) "You should listen to music when you feel stress." The nurse should encourage the client to listen to music to increase relaxation.

A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? A) Weigh the client at night prior to bedtime. B) Offer liquid supplements to the client. C) Encourage the client to gain 2.3 kg (5 lb) per week. D) Observe the client for up to 30 min after meals.

B) Offer liquid supplements to the client. The nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when he is first admitted.

A nurse is caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse report to the charge nurse? A) A client who has schizophrenia is communicating using echolalia B) A client who has depression is exhibiting anergia C) A client who is manic has been pacing the unit for several hours D) A client who has a phobia is using thought stopping

C) A client who is manic has been pacing the unit for several hours The nurse should identify that excessive physical activity in a client who is experiencing a manic episode places the client at risk for physical exhaustion and possible death. The nurse should report this client's behavior to the charge nurse.

A nurse in a community center is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? A) Emotional detachment B) Paranoia C) Impulsive behavior D) Fear of abandonment

C) Impulsive behavior The nurse should identify that impulsive behavior, self-centeredness, and excessive emotionality are expected findings in a client who has histrionic personality disorder.

A nurse is collecting data from a client who is taking valproic acid for the treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider? A) Drowsiness B) Nausea and vomiting C) Constipation D) Bleeding gums

D) Bleeding gums When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is bleeding gums because of the risk of thrombocytopenia.

A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? A) Flumazenil B) Vitamin K C) Acetylcysteine D) Naloxone

D) Naloxone The nurse should identify that naloxone is an opioid antagonist that is administered to treat the effects of opioid toxicity. Following administration, the nurse should monitor the client's respiratory and neurologic status.

A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? A) The client who has anergia B) The client who demonstrates ambivalence C) The client who demonstrates concrete thinking D) The client who is experiencing command hallucinations

D) The client who is experiencing command hallucinations Because command hallucinations are a risk factor for violence, the greatest risk to this client is injury to self or others. Therefore, the nurse should see this client first.

A nurse is caring for a client who recently lost his child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? A) "Are there times when you feel more upset than others?" B) "Have you had any thoughts of harming yourself?" C) "What type of support system do you currently have?" D) "During difficult times in the past, what did you do to cope?"

B) "Have you had any thoughts of harming yourself?" The greatest risk to this client is self-injury due to suicide. Asking whether or not he has plans to hurt himself is the most important question for the nurse to ask at this time because a positive response can alert the nurse to the need for suicide precautions and intervention.

A nurse is monitoring communication between a client who has alcohol use disorder and her partner. Which of the following communication patterns of the client's partner should the nurse identify as being effective? A) "I can never talk to you because you are always drunk." B) "I become very angry when you get drunk." C) "Because of your drinking, we can't have guests in our home." D) "Don't be mad at the kids. It was my fault that the dishes did not get done."

B) "I become very angry when you get drunk." The nurse should identify that this statement is an example of a healthy, effective communication pattern. The partner is discussing personal feelings instead of focusing on the client's negative behavior.

A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan? A) The client will participate in assertiveness training. B) The client will discuss feelings that cause hostility. C) The client will describe an activity she found enjoyable. D) The client will dress in a manner appropriate for the setting and temperature.

B) The client will discuss feelings that cause hostility. Clients who have antisocial personality disorder are frequently aggressive and are at risk for injuring themselves or others. A short-term goal for these clients should be to discuss feelings that precipitate aggression or hostility.

A nurse is reinforcing teaching with the parents of an adolescent who has amphetamine use disorder. Which of the following statements by the parent should the nurse identify as indicating an understanding of the teaching? A) "I should be alert for weight gain in my child." B) "I can tell my child is using amphetamines because he is drowsy." C) "Dilated pupils are a sign my child is using amphetamines." D) "Memory loss can indicate that my child is using amphetamines."

C) "Dilated pupils are a sign my child is using amphetamines." The nurse should instruct the parent to monitor the adolescent for mydriasis, or dilated pupils, because this is a manifestation of amphetamine use.

A nurse is preparing to administer lithium 450 mg PO to a client who has bipolar disorder. Available is lithium 150 mg capsules. How many capsules should the nurse administer?

450/150= 3 capsules

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse anticipate? A) Elevated blood pressure B) Decreased heart rate C) Slurred speech D) Rhinorrhea

A) Elevated blood pressure Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to 12 hr of cessation of alcohol ingestion.

A nurse is attempting to resolve an ethical dilemma that involve a client's medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? A) Discuss information about the dilemma with the client's provider. B) Determine the benefits and consequences of respecting the client's medical decisions. C) Reflect on the effect of ethical theories on the nurse's personal values. D) Develop a plan that balances both the nurse's values and the client's medical decisions.

B) Determine the benefits and consequences of respecting the client's medical decisions. The first action the nurse should take using the nursing process is to collect data from the client. After the nurse collects the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the client's medical decisions as the next step in the ethical decision-making model.

A nurse on a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following statements indicates an understanding of the teaching? A) "The consent form should be written at a seventh-grade reading level." B) "If the consent form is signed, I can send a client for a procedure even if she has questions." C) "I should explain everything to the client about the procedure before the client signs the consent form." D) "The consent form should have the name of the provider who is performing the procedure on the form."

D) "The consent form should have the name of the provider who is performing the procedure on the form." The consent form should include the name of the provider who will be performing the procedure. This should be present on the form before the client signs it.

A nurse on an inpatient mental health unit is supervising a group of clients in the unit's dayroom. The nurse fails to respond to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable? Battery Nonmaleficence Negligence Boundary violation

Negligence The nurse is liable for negligence by failing to respond to the client's escalating, aggressive behavior and prevent harm to others.

A nurse is assisting in the morning hygiene care of a client who is cognitively impaired. Which of the following statements should the nurse make? A) "Let me help you get your toothbrush." B) "Do you want to take a bath or brush your teeth first?" C) "Do you need help brushing your teeth?" D) "Let me inspect the inside of your mouth to see if your teeth are clean."

A) "Let me help you get your toothbrush." A client who is cognitively impaired needs guidance in performing ADLs and should be given one simple task at a time.

A nurse is caring for four clients who are displaying the use of defense mechanisms. Which of the following clients should the nurse identify as using a maladaptive defense mechanism? A) A client who has multiple sclerosis stops taking her medication and says her diagnosis is wrong. B) An adolescent client who has difficulty with reading becomes a star athlete. C) A client admires a high school principal who separated two students who were having a fight. D) A client who has a gambling disorder volunteers in a head start program.

A) A client who has multiple sclerosis stops taking her medication and says her diagnosis is wrong. Suppression is the blocking of thoughts or feelings that a client finds unacceptable. Denying the presence of an illness is a maladaptive use of a defense mechanism.

A nurse is participating in group therapy for clients who have major depressive disorder. Which of the following topics should the nurse include in the orientation phase of group therapy? A) Confidentiality B) Developing goals C) Problem solving D) Identifying the roles of group members

A) Confidentiality The nurse should establish the expectations of confidentiality during the orientation phase of group therapy.

A nurse is contributing to the plan of care for a client who has an anxiety disorder. Which of the following interventions should the nurse recommend be included in the plan? A) Help the client to identify situations that trigger his anxiety. B) Change the subject when the client has anxious feelings. C) Give detailed explanations of available activities. D) Encourage the client to determine his own daily schedules.

A) Help the client to identify situations that trigger his anxiety. The nurse should assist the client in identifying trigger situations to interrupt anxiety escalation in the future.

A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as a predisposing factor for delirium? A) Hepatic failure B) Chronic alcohol use C) Hypertension D) Fluid volume overload

A) Hepatic failure Hepatic failure can be a predisposing factor for the development of delirium. Other potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke.

A nurse is reinforcing teaching with a client who has a new prescription for phenelzine. The nurse should instruct the client that eating foods containing tyramine can cause which of the following adverse reactions with this medication? A) Hypertensive crisis B) Serotonin syndrome C) Hearing loss D) Urinary incontinence

A) Hypertensive crisis Tyramine can cause severe hypertension in clients who are taking phenelzine, a monoamine oxidase inhibitor. Manifestations include palpitations, stiff neck, headache, nausea, vomiting, and elevated temperature.

A nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. Which of the following interventions should the nurse include in the plan? A) Restrict the client's sodium intake. B) Encourage the client to eat three large meals per day. C) Weigh the client weekly. D) Observe the client for 1 hr after he eats.

A) Restrict the client's sodium intake. A client who is malnourished due to alcohol use disorder is at risk for ascites. Therefore, the nurse should restrict the client's sodium intake to decrease the risk of fluid retention.

A nurse is caring for a client who is undergoing behavioral therapy for post-traumatic stress disorder (PTSD). The nurse should identify that which of the following findings indicates an improvement in the client's condition? A) The client reports about techniques she uses to promote sleep. B_ The client shows limited emotion when discussing witnessing a traumatic event. C) The client states that she no longer feels like she can trust her partner. D) The client avoids situations that might trigger memories of past trauma.

A) The client reports about techniques she uses to promote sleep. Clients who have PTSD frequently experience disrupted sleep. Therefore, reporting about techniques she uses to promote sleep demonstrates that the client's condition has improved.

A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findings should the nurse identify as manifestations of bulimia nervosa? (Select all) A) Tooth erosion B) Hand calluses C) Lanugo D) Amenorrhea E) Hypokalemia

A) Tooth erosion B) Hand calluses E) Hypokalemia

A nurse is collecting data from a client who has agoraphobia. The nurse should identify that which of the following situations will increase the client's anxiety? A) Traveling in an airplane B) Entering a walk-in closet C) Taking a bath D) Picking up a soiled tissue

A) Traveling in an airplane The nurse should identify that using public transportation, such as traveling in an airplane, will increase the anxiety of a client who has agoraphobia.

A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? A) "If you can control your actions this week, I'll talk to your parents about extending your curfew." B) "Have you considered participating in a sport to help control your aggression?" C) "If you become aggressive, your parents will take away privileges." D) "You're hurting others. Do you understand why that's wrong?"

B) "Have you considered participating in a sport to help control your aggression?" The nurse should encourage the client to participate in sports and other physical activities because they can provide a safer outlet for aggression.

A nurse is caring for a client who states that she does not want to go to physical therapy after having a below-the-knee amputation. Which of the following responses should the nurse make? A) "Are you afraid that physical therapy will hurt?" B) "What are your feelings about going to physical therapy?" C) "I know you'll make the right decision about going to physical therapy." D) "You will feel better after going to physical therapy."

B) "What are your feelings about going to physical therapy?" The nurse should ask the client open-ended questions because they are therapeutic and allow the client to further discuss her feelings.

A nurse is contributing to the plan of care for a school-age child who has attention deficit hyperactivity disorder. Which of the following interventions should the nurse recommend? A) Avoid the use of humor when managing the child's disruptive behaviors. B) Instruct the child to apologize for behavior that negatively affects others. C) Maintain a scheduled plan of activities regardless of the child's behavior. D) Administer methylphenidate PRN when the child exhibits disruptive behavior.

B) Instruct the child to apologize for behavior that negatively affects others. The nurse should recommend performing simple techniques to manage the child's behavior, including making amends. This technique includes apologizing to others when the client's behavior has a negative effect.

A nurse is collecting data from a client who is experiencing severe anxiety. Which of the following manifestations should the nurse expect? A) Increased salivation B) Sighing C) Bradycardia D) Urinary retention

B) Sighing The nurse should identify that a client who has severe anxiety can display respiratory manifestations, including sighing, constriction of the chest, and dyspnea.

A nurse is collecting data from a client who uses alcohol "to cope with stress." Which of the following questions should the nurse ask? A) "Do you see how your alcohol consumption affects your employment?" B) "Is your partner affected by your alcohol consumption?" C) "What daily activities are disrupted because of your alcohol consumption?" D) "Would you agree that stressful times in your life lead to increased alcohol consumption?"

C) "What daily activities are disrupted because of your alcohol consumption?" The nurse is using an open-ended question, which is a therapeutic form of communication that can encourage the client to share information and to develop a rapport with the nurse.

A nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse take to demonstrate modeling as a behavioral intervention strategy? A) Setting a time limit between episodes of hand hygiene B) Reminding the client to shout "stop" each time she has an urge to perform hand hygiene C) Demonstrating performing hand hygiene at appropriate times D) Instructing the client to practice muscle relaxation when she has the urge to perform hand hygiene

C) Demonstrating performing hand hygiene at appropriate times This action is an example of modeling, which is a strategy that allows the client to see another person perform the expected behavior.

A nurse is caring for a client who has psychiatric somatic symptom disorder. Which of the following actions should the nurse take? A) Obtain the client's vital signs each time the client reports physical illness. B) Remind the client that his symptoms are not real. C) Encourage the client to examine how his illness behavior affects his family. D) Provide adequate time for the client to describe his symptoms.

C) Encourage the client to examine how his illness behavior affects his family. The nurse should recognize that secondary gains the client might receive are a reprieve from performing duties related to care of the family. The nurse should encourage the client to gain insight into how his illness behavior affects his family, which can help restore family function.

A nurse is assisting with the admission of a client to an acute care mental health facility. Which of the following activities should the nurse plan for the working phase of the therapeutic relationship? A) Define the specific responsibilities of the client and of the nurse. B) Assist the client to establish mutual goals. C) Evaluate the client's progress toward meeting his goals. D) Discuss how the client can incorporate new strategies into his daily life.

C) Evaluate the client's progress toward meeting his goals. The nurse should evaluate the progress the client is making toward the goals he has established as part of the working phase of the therapeutic relationship. During the working phase, the nurse and the client identify and implement measures to help the client meet his goals.

A nurse is caring for a client who reports recent amphetamine use. Which of the following manifestations should the nurse expect? A) Akathisia B) Diaphoresis C) Paranoia D) Catatonia

C) Paranoia Paranoia, anxiety, and panic are adverse effects of amphetamine intoxication and are common with stimulant use.

A nurse is talking with a client who has borderline personality disorder. The client states she is lonely and thinks the other nurses avoid her, but she is afraid to share this concern with the other staff. Which of the following actions should the nurse take? A) Encourage the use of transference in the nurse-client relationship. B) Offer to talk to the staff until the client gains an increased level of trust. C) Role-play this situation so the client can gain confidence in expressing her feelings. D) Ask the client why she thinks the staff is avoiding her.

C) Role-play this situation so the client can gain confidence in expressing her feelings. Role-playing can provide practice in a safe environment where the client can learn new behaviors or skills. This can help increase the client's comfort in expressing concerns directly to other members of staff.

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A) Keep the client's room dark at night. B) Alternate the client's caregivers on a routine basis. C) Stand in front of the client when speaking. D) Remove personal belongings from the client's room.

C) Stand in front of the client when speaking. The nurse should stand in front of the client when speaking to her to maintain eye contact and maximize the client's understanding of the conversation.

A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and begins throwing objects at staff and other clients. After calling for assistance, which of the following actions should the nurse take next? A) Obtain a prescription for mechanical restraints. B) Place the client in a monitored seclusion room. C) Tell the client calmly to sit down. D) Administer diazepam intramuscularly.

C) Tell the client calmly to sit down. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should use verbal de-escalation techniques after calling for assistance for a client who is aggressive.

A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider? A) Fasting blood glucose B) Temperature C) WBC count D) Heart rate

C) WBC count The nurse should identify that a WBC count of 3,000/mm3 is below the expected reference range of 5,000 to 10,000/mm3. The nurse should identify that clozapine can cause agranulocytosis, a decrease in white blood cells, which can be life threatening. Therefore, the nurse should withhold the client's medications and notify the provider of this finding.

A nurse is caring for a client who states, "This has been the worst day of my life." Which of the following responses should the nurse make? A) "You should focus on positive thoughts." B) "Everybody has a bad day now and then." C) "Tomorrow will be a better day." D) "Tell me about your day."

D) "Tell me about your day." The nurse should encourage the client to discuss the events of his day because this is a therapeutic communication technique that examines the client's perception of the day's events.

A nurse is planning to collect data from a group of clients. The nurse should expect that which of the following clients is likely to exhibit speech pattern alterations? A) A client who has antisocial personality disorder B) A client who has dependent personality disorder C) A client who has bulimia nervosa D) A client who has schizophrenia

D) A client who has schizophrenia The nurse should expect a client who has schizophrenia to exhibit alterations in behavior, alterations in perception, and alterations in their speech pattern. Speech pattern alterations include associative looseness, clang association, neologisms, and echolalia.

A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the following actions should the nurse take? A) Keep the client lying in a supine position for 2 hr. B) Administer oxycodone/acetaminophen to the client. C) Keep the client NPO for 6 hr. D) Administer oxygen to the client.

D) Administer oxygen to the client. In preparation for ECT, an anesthesiologist administers succinylcholine to the client, which paralyzes respiratory muscles. After the procedure, clients require oxygen administration until their respiratory status is stable.

A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take when caring for this client? A) Persuade the client to demonstrate acceptable behavior. B) Avoid talking about the client's past display of unacceptable behavior. C) Use countertransference to develop the therapeutic relationship. D) Remind the client of consequences for unacceptable behavior.

D) Remind the client of consequences for unacceptable behavior. Clients who have an antisocial personality disorder do not respect the rights of others. Therefore, the nurse should remind the client about which behaviors are acceptable and unacceptable and be prepared to administer consequences for unacceptable behavior.

A nurse is collecting data from a client who has a history of cocaine use. Which of the following manifestations is an indication that the client is experiencing cocaine toxicity? A) Hypothermia B) Piloerection C) Somnolence D) Seizures

D) Seizures The nurse should expect a client who is experiencing cocaine toxicity to experience seizures. Other manifestations include severe anxiety, hallucinations, and paranoid thoughts.

A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The nurse should identify that which of the following findings indicates a potential need for a PRN dose of benztropine? A) Sore throat B) Increased mental confusion C) Urinary retention D) Shuffling gait

D) Shuffling gait The nurse should identify that a shuffling gait can be indicative of the presence of pseudoparkinsonism, which can be treated with a PRN dose of benztropine.

A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? A) Potassium 4.0 mEq/L B) Lithium 0.9 mEq/L C) BUN 12 mg/dL D) Sodium 132 mEq/L

D) Sodium 132 mEq/L The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider.

A nurse is collecting data from a client who has dementia and whose family expresses concern about his increasing "memory problems." Which of the following findings should the nurse identify as the priority? A) The client often forgets people's names. B) The client avoids social interaction. C) The client is frequently emotionally labile. D) The client sometimes wanders from the house.

D) The client sometimes wanders from the house. The nurse should identify that wandering away from home places the client at greatest risk for injury due to lack of supervision. Therefore, this is the priority finding.