Mental Health Exam 2 NCLEX questions

a nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. which priority nursing intervention will the nurse include in the plan of care? 1.one to one suicide precautions 2.suicide precautions, with 30 minute checks 3.checking the whereabouts of the client every 15 minutes 4.asking that the client report suicidal thoughts immediately

1.one to one suicide precautions

which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1.the client gives away a prized CD and a cherished autographed picture of the performer 2.the client runs out of the therapy group swearing at the group leader and then runs to her room 3.the client gets angry with her roommate when the roommate borrows her clothes without asking 4.the client becomes angry while speaking on the telephone and slams the receiver down on the hoo

1.the client gives away a prized CD and a cherished autographed picture of the performer

a client taking lithium carbonate (Lithobid) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. the lithium level is checked as part of the routine follow-up and the level is 3.0 mEq/L. the nurse knows that this level is: 1.toxic 2.Normal 3.slightly above normal excessively below normal

1.toxic

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client 2.ensure that the client knows that he or she is not in charge of the nursing unit 3.assist the client in developing means of setting limits on personal behavior 4.follow through about the consequences of behavior in a nonpunitive manner 5.enforce rules and inform the client that he or she will not be allo

1.Communicate expected behaviors to the client 3.assist the client in developing means of setting limits on personal behavior 4.follow through about the consequences of behavior in a non-punitive manner 6.be clear with the client regarding the consequences of exceeding limits set regarding behavior

a nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1.Provide safety for the client and other clients on the unit 2.Provide the clients on the unit with a sense of comfort and safety 3. Assist the staff in caring for the client in a controlled environment 4.offer the client a less-stimulating area

1.Provide safety for the client and other clients on the unit

a client is unwilling to go out of the house for fear of "doing something crazy in public". Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has: 1.agoraphobia 2.hematophobia 3.claustrophobia 4.hypochondriasis

1.agoraphobia

a nurse is collecting data from a client and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). which disorder would the nurse suspect that this client may have based on the use of this medication? 1.dementia 2.schizophrenia 3.seizure disorder 4.obsessive-compulsive disorder

1.dementia

a manic client announces to everyone in the day room that a stripper is coming to perform that evening. when the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: 1.escort the manic client to his or her room 2.orient the client to time, person, and place 3.tell the

1.escort the manic client to his or her room

a client experiencing a severe major depressive episode is unable to address activities of daily living. the appropriate nursing intervention is to: 1.feed, bathe, and dress the client as needed until the client can perform these activities independently. 2.offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3.structure the client's day so that adequate time can be devoted to the client's assuming responsibility for

1.feed, bathe, and dress the client as needed until the client can perform these activities independently.

a hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. the nurse instructs the client to avoid consuming which foods while taking this medication? Select all that apply. 1.figs 2.yogurt 3.crackers 4.aged cheese 5.tossed salad 6.oatmeal cookies

1.figs 2.yogurt 4.aged cheese

a client taking buspirone (buspar) for 1 month returns to the clinic for a follow-up visit. which of the following would indicate medication effectiveness? 1.no rapid heartbeats or anxiety 2.no paranoid thought process 3.no thought broadcasting or delusions 4.no reports of alcohol withdrawal symptoms

1.no rapid heartbeats or anxiety

a client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on: 1.weight loss 2.sleep patterns 3.medication compliance 4.onset of the crying spells

1.weight loss

a nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client? 1.a puzzle 2.drawing 3.checkers 4.paint by number

2.drawing

the police arrive at the emergency room with a client who has seriously lacerated both wrists. the initial nursing action is to: 1.administer an anti anxiety agent 2.examine and treat the wound sites 3.secure and record a detailed history 4.encourage and assist the client to vent feelings

2.examine and treat the wound sites

a nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (prozac) what information would be important for the nurse to gather regarding the adverse effects related to the medication? 1.cardiovascular symptoms 2.gastrointestinal dysfunctions 3.problem with mouth dryness 4.problems with excessive sweating

2.gastrointestinal dysfunctions

a mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive" and "hangs out with the wrong crowd". In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother: 1.restrict the daughters socializing time with her friends. 2.restrict the amount of chocolate and caffeine products in the home 3.keep her daughter out of s

2.restrict the amount of chocolate and caffeine products in the home

a nurse is reviewing the health care record of a client admitted to the psychiatric unit. the nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. the nurse would determine that this type of crisis could be caused by: 1.witnessing a murder 2.the death of a loved one 3.a fire that destroyed the client's home 4.a recent rape episode experienced by the client.

2.the death of a loved one

a client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to: 1.move the client next to the nurse's station 2.use a night light and turn off the television 3.keep up the television and a soft light on during the night. 4.play soft music during the night and maintain a well-lit room

2.use a night light and turn off the television

Fluoxetine (Prozac) is prescribed for the client. the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication? 1."I should take the medication with my evening meal" 2."i should take the medication at noon with an antacid" 3."I should take the medication in the morning when i first arise" 4.I should take the medication right before bed time with a snack"

3."I should take the medication in the morning when i first arise"

an older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills? 1."i will be more careful to make sure that my father's needs are met" 2."now that my father is moving into my home, I will need to change my ways" 3."i feel better able to care for my father now that I know where to obtain assistance" 4."I am so sorry and embarrassed that the

3."i feel better able to care for my father now that I know where to obtain assistance"

a nurse is collecting data on a client who is actively hallucinating. WHich nursing statement would be therapeutic at this time? 1."I know you feel they are out to get you, but its not true" 2."I can hear the voice and she wants you to come to dinner" 3."sometimes people hear things or voices others can't hear" 4."I talked to the voices you're hearing and they won't hurt you now"

3."sometimes people hear things or voices others can't hear"

a nurse is gathering data from a client in crisis. when determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is: 1."with whom do you live?" 2."who is available to help you?' 3."what leads you to seek help now?" 4."what do you usually do to feel better?"

3."what leads you to seek help now?"

a client who is diagnosed with pedophilia and has been recently paroled as a sex offender says "Im in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it" which of the following is an appropriate response by the nurse? 1. "when children are hurt as you hurt them, people want you isolated" 2. "you're lucky it doesn't escalate into something pretty scary after your crime" 3."you understand that people fear for thei

3."you understand that people fear for their children, but you're feeling unfairly treated?"

a nurse is caring for a hospitalized client who has been taking clozapine (clozaril) for the treatment of schizophrenic disorder. which laboratory study prescribed for the client will the nurse specifically review to monitor for an adverse effect associated with the use of this medication? 1.platelet count 2.cholesterol level 3.WBC 4.Blood urea nitrogen level

3.WBC

a client receiving a tricyclic antidepressent arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? 1.reports not going to work for this past week 2.complains of not being able to "do anything" anymore 3.arrives at the clinic neat and appropriate in appearance 4.reports sleeping 12 hours per night and 3 to 4 hours during the day

3.arrives at the clinic neat and appropriate in appearance

a client was admitted to a medical unit with acute blindness. many tests are performed and there seems to be no organic reason why this client cannot see. the nurse latter learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. the nurse suspects that the client may be experiencing a: 1.psychosis 2.repression 3.conversion disorder 4.dissociative disorder

3.conversion disorder

a nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing 2.make the decisions for the family 3.encourage expression of feelings, concerns, and fears 4.explain everything that is happening to all family members 5.extend touch and hold the client's or family member's hand if appropriate 6.Be honest and truthful and le

3.encourage expression of feelings, concerns, and fears 5.extend touch and hold the client's or family member's hand if appropriate 6.Be honest and truthful and let the client family know that you will not abandon them.

a client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of buprotion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which of the following? 1.insomnia 2.weight gain 3.seizure activity 4.orthostatic hypotension

3.seizure activity

a nurse is caring for a client diagnosed with catatonic stupor. the client is lying on the bed, with the body pulled into a fetal position. the appropriate nursing intervention is which of the following? 1.ask direct questions to encourage talking. 2.leave the client alone and intermittently check on him. 3.sit beside the client in silence and verbalize occasional open-ended questions. 4.take the client into the dayroom with other clients so they can help watch him

3.sit beside the client in silence and verbalize occasional open-ended questions.

a nurse notes documentation in a client's record that the client is experiencing delusions of persecution. THe nurse understands that these types of delusions are characteristics of which of the following? 1.the false belief that one is a very powerful person. 2.the false belief that one is very important person 3.the false belief that one is being singled out for harm by others 4.the false belief that one's partner is going out with other people

3.the false belief that one is being singled out for harm by others

a nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. which statement would be appropriate to make to this client? 1."you need to stop that behavior now" 2."you will need to be placed in seclusion" 3.what is causing you to become agitated" 4."you will need to be restrained if you do not change your behavior"

3.what is causing you to become agitated"

a nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states: 1. "my medications won't make me anxious" 2. "i'll go to a support group and talk so that I won't hurt anyone." 3."I won't get anxious or hear things if I get enough sleep and eat well" 4."I can call

4."I can call my therapist when Im hallucinating so that I can talk about my feelings and plans and not hurt anyone"

a nurse is caring for an older adult client who has recently lost her husband. The client says, "no one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1."right! why not just pack it in?" 2."that seems rather unlikely to me" 3."i don't believe that, and neither do you" 4."you must be feeling all alone at this point"

4."you must be feeling all alone at this point"

during a conversation with a depressed client on psychiatric unit, the client says to the nurse, "My family would be better off without me" the nurse should make which therapeutic response to the client? 1."have you talked to your family about this?" 2."everyone feels this way when they are depressed" 3."you will feel better once your medication begins to work" 4."you sound very upset. are you thinking of hurting yourself?"

4."you sound very upset. are you thinking of hurting yourself?"

a nurse is assisting in developing a plan of care for the client in a crisis state. when developing the plan, the nurse will consider which of the following? 1.a crisis state indicates that the individual is suffering from a mental illness 2.a crisis state indicates that the individual is suffering from an emotional illness 3.Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. 4.a client's response to a crisis is individualized, and what constitutes

4.a client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

a nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. THe nurse avoids which intervention in the plan of care? 1.facing the client when providing care 2.ensuring that a security officer is within the immediate area 3.keeping the door to the client's room open when with the client 4.assigning the client to a room at the end of the hall to prevent disturbing the other clients.

4.assigning the client to a room at the end of the hall to prevent disturbing the other clients.

a client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. the client's mother begins to cry and states, "my child's brain will be destroyed. How can the doctor do this?" the nurse makes which therapeutic response? 1."it sounds as though you need to speak to the psychiatrist." 2."perhaps you'd like to see the ECT room and speak to the staff" 3.your child has decided to have this t

4.it sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

a nurse is caring for a client with a diagnosis of depression. the nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by: 1.poor dietary choices 2.lack of exercise and poor diet 3.inadequate dietary intake and dehydration 4.psychomotor retardation and side effects of medication

4.psychomotor retardation and side effects of medication

Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. the nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? 1.a history of hyperthyroidism 2.a history of diabetes insipid us 3.when the last full meal was consumed 4.when the last alcoholic drink was consumed

4.when the last alcoholic drink was consumed

a client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. the nurse's most important aspect of care is to maintain client safety and plans to: 1.request that a peer remain with the client at all times 2.remove the client's clothing and place the client in a hospital gown. 3.assign a staff member to the client who will remain with him or her at all times 4.admit the client to a seclusion room where all potentially dangerous articles are removed

will remain with him or her at all times