Mental Health Exam 1
If a client attempts to hit another patient or a staff member, which response would be the most appropriate intervention?
"Converses appropriately, clothing matched, participates in activities."
Danny, age 15, was admitted to a psychiatric unit following a violent physical outburst. He asks the nurse to promise to keep confidential a plan he has to kill his father. Which response would be therapeutic?
"I am obligated to share information with the treatment team."
A client diagnosed with schizophrenia approaches the nurse and says, "The voices are bothering me. They're yelling and telling me I'm bad. Can't you hear them?" The most helpful reply for the nurse to make would be:
"I can't hear the voices, but I can see that you're upset."
A patient is pacing the hall near the nurses' station, swearing loudy. An appropriate initial intervention would be for the nurse to say:
"Mr. Olson. You seem pretty upset. Tell me about it."
Which of the following remarks would be most effective for a student nurse to use after introductions have been made in order to begin the first nurse-client interview?
"Perhaps we could begin by telling me about yourself and what brought you to the hospital."
The mother of a newly diagnosed client with schizophrenia tells the nurse, "My neighbor told me that my son's condition is caused by early childhood experiences. I simply don't understand what I did wrong to make this happen to my son." The most appropriate response by the nurse would be:
"Research tells us that your son's condition is a result of biological factors, not early parenting."
A geriatric nurse is teaching the client's family about the possible cause of delirium. Which statement by the nurse is most accurate?
"Taking multiple medications may lead to adverse interactions or toxicity."
What statement given below would show that the RN has empathy for Molly, a client who has recently made a suicide attempt?
"You must have been very upset to do what you did today."
A client prescribed lithium carbonate (lithium) 300 mg two times a day 3 months ago is brought into the hospital emergency department with mental confusion, excessive diluted urine output, and consistent tremors. Which lithium level would the nurse expect to see?
2.2 mEq/L
A client has been diagnosed with delirium caused by a metabolic disorder. He begs the nurse to get someone to take away the huge snake in the hallway before it comes into his room. The nurse looks to where he is pointing and sees the hose of the vacuum cleaner being used by the housekeeper. The nurse can assess this symptom as:
A visual illusion.
Which of the following would be considered a "negative" symptom of schizophrenia?
Anhedonia.
A nursing care plan for a hospitalized client who is hyperactive in a manic episode must include:
Attention to adequate food and fluid.
Which nursing behavior will enhance the establishment of a trusting relationship with a patient diagnosed with schizophrenia spectrum disorder?
Being reliable, honest, and consistent during all interactions.
Patty has delusions and hallucinations. Before beginning treatment with psychotropic drugs, the physician wishes to rule out the presence of a brain tumor. For which test is the nurse most likely to prepare Patty?
CT, MRI
An important facet of nursing care for a client with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations is:
Careful observation and supervision.
A patient with a diagnosis of schizophrenia says to the nurse, "I'm like a fallen star, but I won't go into a bar it would be a mar on my family, on the tar." This is an example of:
Clang association
The nursing diagnosis, Self-Esteem Disturbance related to feelings of abandonment as evidenced by feelings of worthlessness has been established for a patient. Identify an appropriate short-term goal.
Client will verbalize two positive things about herself by (date).
A nursing care plan includes the nursing order, assess for auditory hallucinations. What behavior suggests the client may be hallucinating?
Darting eyes, tilted head, mumbling to self.
Ongoing assessment for a client with schizophrenia is facilitated if the nurse understands that the typical antipsychotic (fluphenazine) prescribed to reduce the client's symptoms targets the neurotransmitter
Dopamine.
The nurse must plan interventions directed toward meeting the client goal: Client will remain safe during hospitalization with the assistance of staff. Which nursing intervention is related to this goal?
Implement suicide precautions.
An appropriate goal for the treatment plan of a client with manic behavior would be that client will demonstrate:
Increased ability to concentrate.
Which effect on the synaptic gap is produced by substances that block neurotransmitter reuptake?
Increased concentration of neurotransmitter in the synaptic gap
Jane, a college student, attempted suicide via overdose. She was treated in the ED and the decision was made to hospitalize her. Jane is placed on the most stringent level of suicide precautions. What nursing interventions would be planned?
Maintain arm's length one-on-one nursing observation around the clock; no glass or metal on meal trays.
A client receiving risperidone (Risperdal) reports severe muscle stiffness mid-morning. During lunch he has difficulty swallowing food and is noted to drool. When vital signs are taken at 4 PM he is noted to be diaphoretic, with a temperature elevation of 38.4 C, pulse of 110 beats/minute, and blood pressure of 150/90 mm Hg. The nurse should suspect:
Neuroleptic malignant syndrome and notify the physician STAT.
A client with a diagnosis of schizophrenia has received typical antipsychotics for a year. His hallucinations are less intrusive, but the client remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might expect the psychiatrist to prescribe:
Olanzapine (Zyprexa).
A patient is newly diagnosed with paranoid schizophrenia. He is withdrawn, suspicious, and aloof. One of his nursing diagnoses is Deficient diversional activity. What activity would be appropriate to plan for him?
Paint-by-number.
Which of the following behaviors indicates that the RN, Pam, may have to address the possibility of countertransference with the client Greg?
Pam calls after her shift to see how Greg is doing
A client recently prescribed venlafaxine (Effexor) 37.5 mg two times a day complains of dry mouth, orthostatic hypotension, and blurred vision. Which nursing intervention is appropriate?
Reassure the client that the side effects are transient, and teach ways to deal with them.
The nurse reads that a certain medication will potentiate the action of GABA. The nurse can expect that the client receiving the medication will demonstrate:
Reduced anxiety
A patient diagnosed with Alzheimer's Disease exhibits progressive memory loss, diminished cognitive functioning, and verbal agression upon experiencing frustration. Which nursing intervention is most appropriate?
Schedule structured daily routines
A 19-year-old client is brought to the emergency department because the client slashed both wrists. What is the nurse's first concern?
Stabilization of physical condition
The priority nursing interventions for the period immediately after electroconvulsive therapy treatment focus on:
Supporting physiological stability.
A nurse prepares to assess a patient using the Abnormal Involuntary Movement Scale (AIMS). Which side effect of antipsychotic medications led to the use of this assessment tool?
Tardive dyskinesia
Which of the following interventions may constitute an example of false imprisonment?
The client has be "pesky", seeking the attention of nurses in the nurses' station much of the day. Now the nurse escorts him to his room and tells him to stay there or he'll put him into seclusion.
The client who is involuntarily committed to an inpatient psychiatric unit loses which of the following rights?
The client loses no rights
Information given to a depressed client and his family when the client is begun on tricyclic antidepressant therapy should include:
The fact that mood improvement may take 10-14 days.
Which intervention is an example of a breach of a client's constitutional right to privacy?
The nurse releases information to the client's employer regarding his condition without the client's consent.
A patient has been assigned an admission diagnosis of Brief Psychotic Disorder. Which assessment information would alert the nurse to question this diagnosis?
The patient has experiened auditory hallucinations for the past 3 hours.
A depressed client is receiving imipramine (Tofranil) 300 mg. daily. Which side effect of this drug would require immediate medical attention?
Urinary retention.
A patient diagnosed with Bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. Inorder to increase adherance which medication should a nurse anticipate that a physician may prescribe?
Valproic acid (Depakote)
The client with a diagnosis of schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse assesses the results of which laboratory study to monitor for adverse effects from his medication?
White blood cell count.
What is the nurse's duty when Paul tells the nurse he plans to kill his wife and her lover as soon as he's released from the hospital? The nurse must
document this information in the client's record and report it to the physician and team
Which of the following clients could the nurse regard as the likely candidate for involuntary commitment for psychiatric treatment?
the client who threatens to harm himself and others
