Mental Health Exam #2
the nurse determines that the wife of an alcoholic client is benefiting from attending an AI-anon group if the nurse hears the wife make which statement?
"I no longer feel that I deserve the beatings my husband inflicts on me."
which question would be a priority when assessing for symptoms of major depression?
"You look really sad. Have you ever thought of harming yourself?"
a hospitalized client has begun taking bupropion as an antidepressant agent. the nurse determines that which is an adverse effect indicating that the client is taking an excessive amount of medication?
seizure activity
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?
"tell me about the incident that causes you to feel like the rape just occurred."
the spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse," I should get out of this bad situation." which is the most helpful response by the nurse?
"what do you find difficult about this situation?"
the nurse is conducting an initial assessment of a client in crisis. when assessing the client's perception of the precipitating event that led to the crisis. which is the most appropriate question?
"what leads you to seek help now?"
the nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. which statement would be most appropriate to make to this client?
"you seem restless, tell me what is happening."
a depressed client on an inpatient unit says to the nurse, "My family would be better off without me." which is the nurse's best response?
"you sound very upset. are you thinking of hurting yourself?"
a client is admitted with a recent hx of severe anxiety following a home invasion and robbery. during the initial assessment interview, which statement by the client should indicate to the nurse the possible dx of PTSD?
-"I keep reliving the robbery." -"I see his face everywhere I go." -"I might have died over a few dollars in my pocket."
the nurse has been closely observing a client who has been displaying aggressive behaviors. the nurse observes that the behavior displayed by the client is escalating. which nursing interventions is most helpful to this client at this time?
-acknowledge the client's behavior -assist the client to a quiet area -maintain a safe distance from the client
a hospitalized client is started on a monoamine oxidase inhibitor for the tx of depression. the nurse should instruct the client that which foods are acceptable to consume while taking this med?
-crackers -tossed salad
the nurse is prepping to perform an admission assessment on a client with a dx of bulimia nervosa. which assessment findings should the nurse expect to note?
-dental decay -loss of tooth enamel -electrolyte imbalances
which interventions are most appropriate for caring for a client in alcohol withdrawal?
-monitor VS -provide a safe environment -address hallucinations therapeutically -provide reality orientation as appropriate
lithium levels
0.8-1.2
the nurse is teaching a client who is being started on imipramine about the medication. the nurse should inform the client to expect maximum desired effects at which time period following initiation of the med
2-3 weeks
the nurse is performing a follow-up teaching session with a client discharged 1 month ago. the client is taking fluoxetine. which info would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the med?
GI dysfunction
Jeff was just diagnosed with a major depressive disorder. Which medication is the HCP most likely to start the pt on?
SSRI
a client with schizophrenia has been started on medication therapy with clozapine. the nurse should assess the results of which laboratory study to monitor for adverse effects from this med?
WBC count
a client with a dx of anorexia nervosa, who is in a state of starvation, is in a 2-bed-room. a newly admitted client will be assigned to this client's room. which client would be the best choice as a roommate for the client with anorexia nervosa?
a client undergoing dx tests
the nurse is creating a plan of care for a client in a crisis state. when developing the plan, the nurse should consider which factor?
a client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client
a client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. the nurse determines that the med is effective if the absence of which manifestation has occurred?
rapid heartbeat or anxiety
the nurse in the ED is caring for a young female victim of sexual assault. the client's physical assessment is complete, and physical evidence has been collected. the nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. how should the nurse interpret these behaviors?
reactions to a devastating event
Jeff's parents have described his lack of interest in things he used to enjoy, like games with his friends, and his classes, which he used to like. This may be best described by the term
annhedonia
the home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
ask the client about the amount of drug use and its effect
the police arrive at the ED with client who has lacerated both wrists. which is the initial nursing action?
assess and tx wound sites
a client is admitted to the mental health unit after an attempted suicide by hanging. the nurse can best ensure client safety by which action?
assigning to the client a staff member who will remain with the client at all times
A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose: A) On an empty stomach B) At the same time each evening C) Evenly spaced around the clock D) As needed when the client complains of depression
at the same time each evening
a client is scheduled for discharge and will be taking phenobarbital for an extended period. the nurse would place highest priority on teaching the client which point that directly relates to client safety?
avoid drinking alcohol taking this med
a hospitalized client with a hx of alcohol misuse tells the nurse,"I am leaving now. I have to go. I don't want any more tx. I have things that I have to do right away." the client has not been discharged and is scheduled for an important dx test to be performed in 1 hour. after the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. what action should the nurse take?
call the nursing supervisor
a client receiving tricyclic antidepressants arrives at the mental health clinic. which observations would indicate that the client is following the med plan correctly
client arrives at the clinic neat and appropriate in appearance
the nurse is reviewing the assessment data of a client admitted to the mental health unit. the nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. the plans care for the client, determining that this type of crisis could be caused by which event?
death of a loved one
a client with anorexia nervosa is a member of a pre-discharge support group. the client verbalizes that she would like to buy some new clothes, but her finances are limited. group members have brought some used clothes to the client to replace the client's old clothes. the client believes that the new clothes are much too tight and has reduced her caloric intake to 800 calories daily. how does the nurse evaluate this behavior?
evidence of client's disturbed body image
a client gives the home health nurse a bottle of clomipramine. the nurse notes that the med has not been taken by the client in 2 months. which behavior observed in the client would validate noncompliance with this med?
frequent hand washing with hot, soapy water
the nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. before discharge, which instruction should the nurse provide to the client?
get up slowly when changing positions
the nurse is assessing a client who was admitted 24 hours ago for a fx humerus. which findings should alert the nurse to the potential for alcohol withdrawal delirium?
hypertension, changes in LOC, hallucinations
the nurse is describing the med side and adverse effects to a client who is taking amitriptyline. which info should the nurse incorporate in the discussion?
increase fluids and bulk in the diet
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed
increasing the level of suicide precautions
the ED nurse is caring for a adult client who is a victim of family violence. which priority info should be included in the discharge instructions?
info regarding shelters
the nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. the nurse enters the client's room and notes that the client is engaged in rigorous push-ups. which nursing action is most appropirate?
interrupt the client and offer to take her for a walk
the nurse is planning care for a client being admitted to the nursing unit who attempted suicide. which priority nursing intervention should the nurse include in the plan of care?
one-to-one suicide precautions
the nurse notes that a client with schizophrenia and receiving an antipsychotic med is moving her mouth, protruding her tongue, and grimacing as she watches tv. the nurse determines that the client is experiencing which med complication
tardive dyskinesia
which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
the adolescent gives away a DVD and a cherished autographed pic of a performer
a client taking lithium reports vomiting abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. the lithium level is 2.5. the nurse plans care based on which representation of this level
toxic
