Mental Health B (2019)
a nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. which of the following assessment findings supports the nurse's suspicion of delirium?
easily distracted
a nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" which of the following responses should the nurse make?
"Let's talk about what is upsetting you."
a nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. the nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?
"I will not take charge of my partner's work responsibilities."
a nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I will update the plan of care as a clients manifestations of depression change"
a nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawl. available is diadepam injection 5mg/mL. how many mL should the nurse administer?
1.5mL
a nurse observes on a mental health unit pushing on the locked unit door. which of the following statements should the nurse make?
"It appears as though you'd like to open the door.''
a nurse is teaching the guardians of a client about their adolescent child's d/x of bulimia nervosa. which of the following statements made by the guardians indicates an understanding of their child's illness?
"It is important for our child to have regular dental checkups."
a nurse is teaching the parent of a 10 year olf child who has adhd and a new Rx for DEXTROAMPHETAMINE. which of the following instructions should the nurse include in the teaching?
"administer the last dose of meds to your child 6 hours before bedtime."
a charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. which of the following statements should the charge nurse make?
"clients who are admitted involuntarily maintain the right to give informed consent for procedures."
a nurse is teaching a client who has bipolar disorder and a Rx for lithium. which of the following instructions should the nurse include in the teaching?
"take this med with food" R: lithium can cause GI distress
a nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. the client states, "I am so fat I cant even stand to look at myself." which of the following therapeutic responses demonstrates the nurses use of summarizing?
"you're saying that you think you're fat and are using laxatives because you are afraid of gaining weight."
a nurse is preparing to discharge to home an older adult client who attempted suicide. the client lives alone and has difficulty performing ADLs. which of the following referrals should the nurse initiate? SATA
-occupational therapy -meal delivery services -physical therapy -home health servoces
a nurse who is working on a mental health unit should recognize that which of the following are indications for the use if ECT? SATA
-pt who is suicidal and need rapid tx -pt with bipolar d/ow rapid cycling -pt with mania and not responding to med therapy
a nurse on a med surge unit is assessing a client who sustained injuries 12 hr ago following a MVA. the clients admission blood alcohol level was 325mg/dl. which of the following findings should indicate to the nurse that client is expierecing alcohol withdrawl?
BP 154/96 mmHg
a nurse is caring for four clients in an ED. the nurse should identify that which of the following clients can give informed consent?
a 35 year old who has MDD
a nurse on an acute mental health facility is receiving change of shift report on four clients. which of the following clients should the nurse assess first?
a client who is experiencing delusions of persecution
a nurse is recieving change of shift report for four clients. which of the following clients should the nurse plan to see first?
a client who is taking clozapine and reports a sore thriat and chills
a nurse who works with newborns is assessing the potential for abuse or neglect. which of the following family groups should the nurse identify as the highest potential for future child abuse?
a family where one or more parents witnessed intimate partner violence in the home as children
a nurse is teaching a group of newly licenced nurses about the use of mechanical restraints. which of the following information should the nurse include in the teaching?
apply retrainsts when other means of managing the client's behavior have failed.
a nurse on a mental health unit observes a client who has acute mania hit another client. which of the following actions should the nurse take first?
call for a team of staff members to help with the situation
a nurse in a ,ental health facility is caring for a client who has schizophrenia. which of the following findings places the client at the greatest risk for self directed injury or injuring others
command hallucinations
a nurse is caring for a client who is recieving hospice care for an inoperable brain tumor. when completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement?
discuss spiritual issues in a conversational manner
a nurse is talking with a client who is beginning chemo. the client tells the nurse that she is mourning the loss of her hair. which of the following actions should the nurse take first?
discuss the importance of hair with the client
a nurse is planning discharge teaching with a family member of a client who has a d/x of depression. which of the following info about relapse should the nurse include?
early identification of changes, such as decreased social involvement, is important
a nurse is planning discharge teaching with a family member of a client who has a new d/x of depression. which of the following info about relapse should the nurse include?
early identification of changes, such as decreased social involvement, is important
a nurse is planning prevention strategies for partner violence in the community. which of the following strategies should the nurse include as a method of secondary prevention?
establish screening programs to identify at risk clients
a nurse in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. which of the following manifestations should the nurse include?
experiences feelings of isolation
a nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. which of the following actions is the first component of a safety plan?
identify signs of escalation of violence
a nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. which of the following interventions should the nurse include in the plan?
identify the client's trigger foods
a nurse is caring for a client who gave birth to a stillborn baby. which of the following statements should the nurse make?
ill stay with you just in case you want to talk
a nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. which of the following statements by the client indicates acceptance of her illness?
im going to oder a wheelchair for when I am unable to walk
a nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. which of the following findings should the client's partner report to the provider?
inability to sleep
a nurse is caring for a client who has alcoholic cardiomyopathy. which of the following lab findings should the nurse expect?
increased creatine phosphokinase (CPK)
a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. to est a trusting nurse client relationship, which of the following actions should the nurse take first?
inform the client that this admission is confidential
a school nurse is assessing a school age child who expierenced the traumatic loss of a parent 8 months aho. which of the following findings should the nurse identify as an indication that the child is exp PTSD?
lack of interest in an upcoming birthday
a nurse is planning care for a client who has GAD. at which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
mild
a nurse is planning care for a client who is to undergo ECT. which of the following actions should the nurse include in the plan?
monitor the client's cardiac rhythm during the procedure
a client who has a recent d/x of bipolar disorder is placed in a room with a client who has severe depression. the client who has depression reports to the nurse, "My roommate never sleeps and keeps me up too." whoch of the following actions should the nurse take?
move the client who has bipolar disorder to a private room
a nurse is planning care for a client who has made repeated physical threats toward others on the unit. although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. which of the following ethical principles should the nurse apply in this situtation?
nonmaleficence
a nurse is planning care for a client who has bipolar disorder and is experiencing mania. what of the following interventions should the nurse include in the plan of care?
offer the client high calorie finger foods during the day
a nurse is assessing a family's dynamics during a counseling session. the nurse should recognize which of the following findings as an indication of a boundary issue?
older children who are responsible for their younger siblings.
a nurse is caring for an older adult client who is experiencing delirium. which of the following interventions should the nurse include in the child's plan of care?
permit the client to perform daily rituals to decrease anxiety.
a nurse is admitting a client who has MDD and a new Rx for tranylcypromine. which of the following OTC meds that the client reports taking should the nurse alert as a potential A/E?
phenyleprine
a nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. which of the following therapeutic interventions is the priority?
reduce enviornmental stimuli
a nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. which of the following interventions should the nurse include in the plan?
renew the Rx for the client Q4h
a nurse is assessing a clients who is experiencing opioid withdrawal. which of the following manifestations should the nurse expect?
rhinorrhea
a nurse in an ED is caring for a female adolescent who has a d/x of bulimia nervosa and had a fainting episode during a ballet performance. which of the following statements by the parent acknowledges the client's d/x?
she wont let me take the trash from her room, I am concered about what she has in there
a nurse on a mental health unit is caring for a group of clients. which of the following actions by the nurse is an example of the ethical principle of justice?
spending adequate time with a client who is verbally abusive
a nurse in a mental health clinic is panning care for 4 clients. which of the following tasks should the nurse delegate to an assistive personnel (AP)?
stay with a client who has anorexia nervosa for 1 hr after mealtimes.
a nurse is caring for a child who is taking methylphenidate. the nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?
tachycardia
a nurse is caring for a client who has moderate Alzheimers disease. which of the following nursing interventions assists in orienting the client to reality?
talk with the client about scheduled daily activities
a nurse is assessing a client for risk factors for the development of depression. the nurse should identify that which of the following factors places the client at an increased risk for depression?
the client has COPD
a nurse is caring for a client who is taking clozapine. for which of the following findings should the nurse withhold the med?
the client reports a sore throat
a nurse is discussing a 12 step program with a client who has an alcohol use disorder and is in an acute care facility undergoing detox. which of the following info should the nurse include in the teaching?
the client should obtain a sponsor before discharge for an increased chance of recovery
a nurse is reviewing lab results for a client who has schizophrenia and is taking clozapine. which of the following values should the nurse identify as a contraindication for receiving clozapine?
WBC count 2,500/mm3
a nurse is reviewing the MAR for a client who is experiencing adverse effects chlorpromazine. the nurse should administer benztropine to relieve which of the following adverse effects?
acute dystonia (an extrapyramidal adverse effect)
a nurse is the ED is caring for 4 clients. which of the following clients is the nurse required to report as a potential victim of abuse?
an older adult client who is bedbound with a pressure ulcer that is stage IV
a nurse is facilitating a community meeting for acute care clients. one client is constantly talking and using the majority of the group's time. which of the following interventions should the nurse implement?
ask group members to discuss their feelings about this clients monopolizing behavior
a nurse is planning discharge teaching for a client who has severe schizoaffective disorder. the nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?
assertive community treatment
a nurse is caring for a client who is experiencing a panic attack. which of the following actions should the nurse take?
assist the client with deep breathing exercises.
a nurse in a mental health clinic is caring for a client who has PTSD after returning from military deployment. which of the following is the priority action for the nurse to take?
stay with the client when the flashbacks occur
a nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. which of the following behaviors is the priority for the nurse to report to the treatment team?
giving away possessions
a nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. which of the following outcomes should the nurse expect?
greater risk of attempting suicide as affect and energy improves. (tricyclic)
a nurse in a community health center is working with a group of clients who have PTSD. which of the following interventions should the nurse include to reduce anxiety among the group members?
guided imagry
a nurse is teaching coping strategies to a client who is exp depression related to partner violence. which of the following statements by the client indicates an understanding of the teaching?
i will talk about my feelings with a close friend
a nurse is caring for a client who is an abusive relationship and is assisting in the development of a safety plan. which of the following actions is the 1st component of a safety plan?
identify signs of escalation of violence
a nurse is educating the parent of a child who has a new d/x of autism spectrum disorder. which of the following manifestations of this disorder should the nurse include in the teaching?
language delay
a nurse is talking with a group of parents who have been recently exp the death of a child. which of the following actions should the nurse take?
suggest forming a weekly support group for parents who have exp the death of a child
a charge nurse is planning a teaching session regarding the code of ethics for RNs which of the following info should the nurse include in the teaching?
the right to treatment ensures individualized care
a charge nurse is developing an educational program about schizophrenia. which of the following manifestations should the nurse include as a negative symptom of schizophrenia.
thought blocking
a nurse is assessing a client who has bulimia nervosa. the nurse should expect which of the following findings?
tooth erosion
a nurse is caring for a client who was admitted following an overdose of amitriptyline. the nurse should monitor the client for which of the following adverse effects associated with this med.
urinary retention
a nurse at a provider's office interviewing an older adult client. which of the following actions should the nurse plan to take?
use a screening tool to evaluate the client for depression.
