mental health exam 2
A nurse is interviewing a client who recently attempted suicide. Which question is appropriate for the nurse to ask the client
"Do you currently have a plan for killing yourself?"
A mental health nurse is conducting a group discussion with lesbian, gay, bisexual, transgender, queer, questioning, intersex, and allies (LGBTQIA) members of the community. One member asks the nurse why there is concern about suicide in the LGBTQIA community. Which is the most appropriate response from the mental health nurse?
"Dominant social beliefs result in discrimination against the LGBTQIA community."
Which neurotransmitter change is frequently associated with suicide?
**Decrease in serotonin
A nurse working in a psychiatric hospital is performing a suicide assessment on a client diagnosed with major depressive disorder (MDD). Which actions by the nurse are appropriate when conducting a suicide assessment? Select all that apply.
- If the client has suicidal thoughts, assess whether or not the client would act on them. - Assess the lethality of the suicide plan, if one exists. - Ask if the client has any thoughts of suicide.
A malfunction in what system is thought to contribute to the development of obsessive-compulsive disorder? A) Cortico-striato-thalamo-cortical circuit B) Hypothalamic-pituitary-adrenal axis C) Microbiome-gut-brain axis D) Frontal-subcortical circuit
A) Cortico-striato-thalamo-cortical circuit
A nurse is conducting an admission assessment on a client admitted for thoughts of suicide. Which assessment findings would indicate that the client is at a high level risk of suicide? Select all that apply[Control] A. Admits planning to end his or her life. B. Has access to a gun at home. C. Displays mild depression. D. Discusses a plan to end his or her life in detail. E. Shows curiosity about death.
A. Admits planning to end his or her life. B. Has access to a gun at home. D. Discusses a plan to end his or her life in detail.
An adolescent client hospitalized with asphyxiation following a suicide attempt tells the nurse, "I know other kids have the same problems I do, but I just wanted to make it stop." Which action by the nurse is the most appropriate?
A. Ask if the client would like to talk about stressors and problems.
An adolescent client hospitalized with asphyxiation following a suicide attempt tells the nurse, "I know other kids have the same problems I do, but I just wanted to make it stop." Which action by the nurse is the most appropriate? A. Ask if the client would like to talk about stressors and problems. B. Suggest the client listen to music and read a light novel to reduce stress. C. Ask what is so devastating that the client needed to commit suicide. D. Discuss the client's attendance at school and what activities are enjoyed.
A. Ask if the client would like to talk about stressors and problems.
A client, who was recently laid off from work, is scheduled for a biopsy to evaluate a site for malignancy. When planning this client's care, which does the nurse include? A. Interventions to address anxiety B.Reasons to delay the biopsy C.Medicate around the clock for pain D.Social services to aid with financial planning
A. Interventions to address anxiety
The nurse is reviewing the medical and social history of a client with depression. Which factor should the nurse recognize as increasing the risk of suicide? (Select all that apply.) The client having bipolar disorder The client's spouse having recently died The client having a history of alcohol abuse The client having a brother who committed suicide
A. The client having bipolar disorder B. The client's spouse having recently died C. The client having a history of alcohol abuse D. The client having a brother who committed suicide
Which statement by the nurse is most appropriate in regard to the etiology of obsessive-compulsive disorder (OCD)? A. Typically begins in adolescence or early adulthood. B. Females are affected more than males C. Manifestations of OCD occur only in children. D. Children have a low chance of experiencing a remission of the disease.
A. Typically begins in adolescence or early adulthood.
A client, who is experiencing anxiety, is trembling and complaining of dizziness and palpitations. The client is having a hard time following the nurse's instructions. Based on this data, which level of anxiety is the client likely experiencing? A.Severe B.Panic C.Moderate D.Mild
A.Severe
A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event
ANS: A, C, D, E
A client receiving pain medication for abdominal discomfort reports no relief of pain and continues to describe multiple somatic complaints. The client also describes feelings of discouragement and hopelessness related to the pain, because the healthcare team has not yet found a cause for the pain. Which action by the nurse is appropriate?
Assessing the client for depression
A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping? A. Allow the patient to set a hand-washing schedule. B. Encourage the patient to participate in social activities.. C. Encourage the patient to discuss hand-washing routines. D. Focus on the patients' symptoms rather than on the patient.
B. Encourage the patient to participate in social activities.
A client who has attempted to commit suicide in the past tells the nurse about feeling better since being prescribed an antidepressant medication. Which conclusion by the nurse is appropriate based on the assessment data?[Control] A. Improved sleep B. Improved mood C. Improved appetite D. Improved feelings of guilt
B. Improved mood
A client states that he often wonders if everyone would be better off if he were dead. What does the nurse identify this as? A. A suicide threat B. Suicidal ideations C. Suicide Planning D. A suicide attempt
B. Suicidal ideations
A nursing instructor is evaluating a nursing student's knowledge regarding a client with suicidal thoughts. Which statement made by the student demonstrates an understanding regarding assessing a client with suicidal thoughts?[Control] A. "I should be indirect and respectful." B. "I should attempt to make light of the circumstances." C. "I should directly acknowledge the situation." D. "I should not talk about suicide directly."
C. "I should directly acknowledge the situation."
The nurse is evaluating medication teaching for a client who recently started taking fluoxetine (Prozac) for anxiety. Which statement by the client indicates appropriate understanding of the information presented? A. "My medication will become effective immediately after I start taking it." B. "My medication will not begin to work for 12 weeks." C. "My medication will take 4 weeks to become effective." D. "My medication will take 1 week to become effective."
C. "My medication will take 4 weeks to become effective."
The nurse is conducting a nursing assessment for a client diagnosed with obsessive-compulsive disorder (OCD). Which findings are indicative of the repetitive acts associated with OCD?Select all that apply. A. Underweight and appears older than stated age B. Poor posture and altered motor skills C. Constant hand washing D. the need to lock and unlock doors E. Poor grooming and stained clothing
C. Constant hand washing D. the need to lock and unlock door
A 76-year-old man was recently diagnosed with Alzheimer disease. His wife passed away 6 months ago due to metastatic breast cancer. The client states that he doesn't sleep well, often forgets to eat because he doesn't feel hungry, and he just doesn't get involved in social functions anymore because his kids don't want him to drive. He states that he feels isolated and lonely. What diagnosis should the nurse include as the highest priority in this client's plan of care? A. Risk for Loneliness B. Ineffective Activity Planning C. Risk for Suicide D. Grieving
C. Risk for Suicide
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?
Concerns stated aloud become less overwhelming and help problem solving begin.
A nurse is interviewing a client who recently attempted suicide. Which question is appropriate for the nurse to ask the client?[Control] A. "Why would you think about harming yourself?" B. "Do you ever think about hurting yourself?" C. "Did you feel unsafe?" D. "Do you currently have a plan for killing yourself?"
D. "Do you currently have a plan for killing yourself?"
(SSRI are antidepressants not Benzos) The nurse is discharging a client diagnosed with general anxiety disorder (GAD). The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which statement made by the client would indicate to the nurse a need for further education? A. "This medicine alters the levels of the neurotransmitter serotonin in the brain." B. "I may experience some nausea while on this medication." C. "This medicine could make me feel like I have the jitters." D. "My doctor will start me off on a high dose and then decrease the dose.
D. "My doctor will start me off on a high dose and then decrease the dose.
The nurse is discharging a client diagnosed with general anxiety disorder (GAD). The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which statement made by the client would indicate to the nurse a need for further education? A. "This medicine alters the levels of the neurotransmitter serotonin in the brain." B. "I may experience some nausea while on this medication." C. "This medicine could make me feel like I have the jitters." D. "My doctor will start me off on a high dose and then decrease the dose."
D. "My doctor will start me off on a high dose and then decrease the dose.
The nurse is discharging a client diagnosed with general anxiety disorder (GAD). The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which statement made by the client would indicate to the nurse a need for further education? A. "This medicine alters the levels of the neurotransmitter serotonin in the brain." B. "I may experience some nausea while on this medication." C. "This medicine could make me feel like I have the jitters." D. "My doctor will start me off on a high dose and then decrease the dose."
D. "My doctor will start me off on a high dose and then decrease the dose."
Which is the priority nursing action when providing care to a client who demonstrates signs of escalating anxiety? A.Leave the client alone in a room. B.Provide a benzodiazepine. C.Phone the physician. D.Isolate the client in a safe, quiet, and protective environment
D.Isolate the client in a safe, quiet, and protective environment
Which is the priority nursing action when providing care to a client who demonstrates signs of escalating anxiety? A.Leave the client alone in a room. B.Provide a benzodiazepine. C.Phone the physician. D.Isolate the client in a safe, quiet, and protective environment.
D.Isolate the client in a safe, quiet, and protective environment.
The nurse is performing an assessment on an 8-year-old child who the mother is concerned has depression. Which symptoms of depression are consistent with a child of this age?
Decrease in academic performance
A client who was widowed 3 years ago states, "I don't have many friends. The only people I visit with are some acquaintances at the local bar." Which health problem does the nurse realize the client is at risk for based on this statement?
Depression
What is the greatest risk for a woman diagnosed with postpartum psychosis?
Infanticide
A nurse is caring for a client who states "I plan to commit suicide"which of the following assessments should the nurse identify as the priority.
Lethality of the method and availability of mean
The home care nurse hears the spouse of a client say "With you being so sick lately, I can't maintain this home by myself, so I never invite family over anymore. I can't stand to have them see our house in this rundown state." The client engages in an argument with the spouse, and the spouse begins to cry. Which does the home care nurse identify as occurring with this couple?
Possible situational depression
The postpartum client states that she cannot understand why she does not enjoy being with her baby. Based on this data, which does the nurse suspect the client is experiencing?
Postpartum depression
A nurse is teaching a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse provide?
Report confusion as a potential indication of toxicity
The nurse is providing teaching to a 71-year-old client who was prescribed escitalopram (Lexapro) for depression. The client is also taking medication for type II diabetes, hypertension, and heart disease. What should the nurse include in her teaching?
The client will need to come in for more frequent monitoring.
A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply
Use a calm manner and low voice Maintain simplicity in the environment Explain and reinforce reality to avoid distortion
A nurse is conducting an admission assessment on a client admitted for thoughts of suicide. Which assessment findings would indicate that the client is at a high level risk of suicide? Select all that apply[Control] a) Admits planning to end his or her life. b) Has access to a gun at home. c) Displays mild depression. d) Discusses a plan to end his or her life in detail. e) Shows curiosity about death.
a) Admits planning to end his or her life. b) Has access to a gun at home. c) Displays mild depression. d) Discusses a plan to end his or her life in detail.
A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you became depressed."
a. "Are you having thoughts of suicide?"
A student says, Before taking a test, I feel very alert and a little restless. Which nursing intervention is most appropriate to assist the student?
a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.
A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply.
a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment.
A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." The parents' reaction reflects: a. guilt. c. shame. b. denial. d. rescue feelings.
a. guilt.
A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).
a. verbalize realistic positive characteristics about self by (date).
The community health nurse is working with a lesbian, gay, bisexual, transgender, queer, questioning, intersex, and allies (LGBTQIA) community group to prevent suicide. Which characteristic does the nurse include in teaching the group about signs of suicidal ideation? (Select all that apply.)
anger, anxiety, hopelessness,
When alprazolam (Xanax) is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to:
avoid alcoholic beverages
Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.) a. "Are there certain social situations that cause you to feel especially uncomfortable?" b. "Are there others in your family who must do things in a certain way to feel comfortable?" c. "Have you been a victim of a crime or seen someone badly injured or killed?" d. "Is it difficult to keep certain thoughts out of your awareness?" e. "Do you do certain things over and over again?"
b. "Are there others in your family who must do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of your awareness?" e. "Do you do certain things over and over again?"
Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."
b. "I have no one to turn to for help or support."
An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor
b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor
A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c.Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family.
b. Present the information again in a calm manner using simple language.
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. suicide potential. c. mood disturbance. d. level of anxiety
b. suicide potential.
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. suicide potential. c. mood disturbance. d. level of anxiety
b. suicide potential.
A nursing instructor is evaluating a nursing student's knowledge regarding a client with suicidal thoughts. Which statement made by the student demonstrates an understanding regarding assessing a client with suicidal thoughts?[Control] a) "I should be indirect and respectful." b) "I should attempt to make light of the circumstances." c) "I should directly acknowledge the situation." d) "I should not talk about suicide directly."
c) "I should directly acknowledge the situation."
A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."
c. "Bringing up these feelings is a very positive action on your part."
A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."
c. "I have a plan that will fix everything."
A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."
c. "I have a plan that will fix everything."
A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room
c. Giving away sweaters
A patient experiencing moderate anxiety says, I feel undone. An appropriate response for the nurse would be: a. What would you like me to do to help you? b. Why do you suppose you are feeling anxious? c. I'm not sure I understand. Give me an example. d. You must get your feelings under control before we can continue.
c. I'm not sure I understand. Give me an example
Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity
c. Situational low self-esteem
Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity
c. Situational low self-esteem
A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide.
c. establish rapport with the patient.
. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to a. assess lethality of suicide plan. b. encourage expression of anger. c. establish trust with the patient. d. determine risk factors for suicide.
c. establish trust with the patient.
patient experiences a sudden episode of severe anxiety. Of these medications in the patients medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone (BuSpar) b. amitriptyline (Elavil) c. lorazepam (Ativan) d. desipramine (Norpramin)
c. lorazepam (Ativan)
A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? a. Assign the client to a private room b. Document the client's behavior every hour c. Allow the client to keep perfume in her room d Ensure the client swallows medication
d Ensure the client swallows medication
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."
d. "Let's consider which problems are very important and which are less important."
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."
d. "Let's consider which problems are very important and which are less important."
Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient
d. Helping school children learn to manage stress and be resilient
A student says, Before taking a test, I feel very alert and a little restless. The nurse can correctly assess the students experience as:
mild anxiety
A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurses comments and asks, What do you mean? What are they going to do? Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patients level of anxiety?
moderate
A person has minor physical injuries after an auto accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is the persons level of anxiety?
severe
A patient with major depression committed suicide in the hospital. What appropriate action should the nurse take?
· Give adequate support to the staff of the unit. · Review the events to find the overlooked clues. · Recommend conducting psychological postmortem.
