Mental health exam 3

The patient has not slept in 24 hours *not fine hand tremors- this is a normal and expected side effect*

A bipolar client is taking valproic acid, what is a priority assessment finding?

D. "I will schedule the client for daily TMS treatments for the first several weeks."

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "TMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following TMS." C."TMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for daily TMS treatments for the first several weeks."

Hostile Behavior

A child who has oppositional defiant disorder is most likely to demonstrate what?

identify the clients nutritional status

A client has lost 25lbs in the last 3 months. She weighs 88 lbs and states that she is fat. What is the first priority?

Urinary retention and other anticholinergic effects.

A depressed client is prescribed imipramine, what side effects should you look for?

Pseudoephedrine

what medication should MAOIs never be mixed with?

over 30% within 6 months

what percentage of weight loss must occur to require a patient be hospitalized?

Explain to the client they need to calm down or they will be dismissed from the group.

in group a bipolar patient begins bragging and dominating the situation- what should the nurse do?

thoughts are dominated by concerns of weight gain; binge-purge; frequent vomiting causes metabolic alkalosis, hypertrophy of parotid glands, puffy cheeks, and edema; hypotension due to dehydration; brittle hair and hair loss due to malnutrition

What are indications of bulimia nervosa?

temperature of 96.1F (Hypothermia due to loss of SQ tissue or dehydration)

What clinical finding in a patient with anorexia would require hospitalization?

Therapeutic holding technique

What intervention is highest priority in a child who has conduct disorder who is being destructive, throwing thing, and kicking others?

calm firm approach provide frequent, high-calorie foods maintain low stimuli environment no group therapy provide frequent rest periods use short statements

What interventions are anticipated for a client with bipolar-mania?

an upcoming suicide attempt- increased risk of suicide

What is to be expected in a depressed patient with increased energy and reports finally being at peace?

"It is easier to talk about my feelings now."

Which statement made by the client with depression would show a decreased suicide risk?

"I am relieved now that my financial affairs are in order."

Which statement made by the client with depression would show an increased suicide risk?

aggressive behavior towards others

a nurse is assessing a client who has conduct disorder which of the following findings should the nurse expect

restrict caffeine (diuretic)

an anorexic client who needs to increase oral intake- what interventions should the nurse take?

make the child pick up books after he threw them all over the room

how do you use simple restitution as a behavior management technique for a child with conduct disorder?

Provide frequent high-calorie snacks

priority action by nurse to client just admitted with bipolar?

no- they are at risk of self harm

should you move a pt with depression to a private room?

No, however, rewards could be used for the amount of calories taken in.

should you offer rewards for the amt of weight gained by a client with an eating D/O?

Secondary prevention

the charge nurse is reviewing suicide precautions with nursing staff, what type of prevention is this an example of?

sodium levels (watch for hyponatremia)

the nurse is providing care for a client hospitalized with bulimia nervosa, what should they monitor?

russel's sign and tooth erosions

what are some basic signs a client is struggling with bulimia nervosa?

less pressured speech less insomnia less grandiose

what is a sign that valproic acid is working for a client diagnosed with bipolar disorder?

decreased socialization

what is an early indication of depression?

amenorrhea

a nurse is assisting a client who is diagnosed with anorexia nervosa, what clinical finding supports this diagnosis?

This is a sign of depression; the client is showing signs of uselessness.

A client in an outpatient clinic states, "I'm not going to my family reunion because no one asked me to help plan it", what is this a sign of?

C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D."Medication and psychotherapy are most effective during the acute phase of MDD."

flat affect anhedonia Feeling hopeless

A nurse is working with a client at an outpatient facility, which of the mentioned symptoms are signs of depression?

A. Age B. Gender C. History of chronic asthma D. Smoking

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply.) A. Age B. Gender C. History of chronic asthma D. Smoking E. Being married

C. "I am aware that my PMDD causes me to have rapid mood swings."

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?

B. Hallucinations D. Diaphoresis E. Agitation

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine (Prozac). Which of the following findings should the nurse report to the provider as an indication of serotonin syndrome? (Select all that apply.) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation

A. Acrocyanosis

A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect? a. Acrocyanosis b. Amenorrhea c. Lanugo d. Hyponatremia

D. Remove the patch each day after 9 hr

A nurse is caring for a school age child who has a new prescription for methylphenidate (Daytrana) to treat ADHD. Which of the following should the nurse teach the client and family about this medication? A. Apply the patch once daily at bedtime. B. Take the medication orally with food every 12 hr. C. Take a second dose of the medication orally at bedtime. D. Remove the patch each day after 9 hr.

B. Yellowing skin D. Fever E. Malaise

A nurse is providing teaching to an adolescent who is to begin taking atomoxetine (Strattera) for ADHD. The nurse should instruct the client to monitor for and report which of the following indications of liver damage? (Select all that apply). A. Mood changes B. Yellowing skin C. Joint pain D. Fever E. Malaise

attending group therapy even if you're tired is an important part of your treatment

a nurse is caring for a client who has a depression the client states I am too tired and depressed to attend group therapy which of the following responses should the nurse make

permitting the client to spend quiet time alone after each meal

a nurse is developing a plan of care for a client who has anorexia nervosa the nurse should identify that which of the following actions is contraindicated for this client

strenuous exercise regimen

a nurse is interviewing a client who has anorexia nervosa which of the following findings should the nurse expect

cardiac arrhythmia

a nurse is obtaining clients medical history prior to scheduling the client for electroconvulsive therapy ECT which of the following findings should the nurse identify as potential complication of the procedure?

decreased calorie intake

a nurse is performing and admission assessment for a client who has a restricting type anorexia nervosa the nurse should expect which of the following findings

early identification of changes such as decreased social involvement is important

a nurse is planning DC teaching to a family member of a pt newly diangosed with depression, what should the nurse teach about relapse?

maintain adequate hydration

a nurse is planning care for a newly admitted client who has a bipolar disorder and is experiencing acute Mania which of the following client goals should the nurse identify as the priority

A. "Care during the continuation phase focuses on treating continued manifestations of MDD."

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The goal of treatment during the maintenance phase is prevention of future episodes of MDD." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are used to prevent a relapse of MDD."

B. Lethality of the method and availability of means

A client says, "I plan to commit suicide." Which of the following should be the nurse's priority assessment? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

Fever-(this is a sign of serotonin syndrome) *not sexual disfunction as this is common and expected*

A client with depression is taking an SSRI like paroxetine, what should you educate the client to report to their provider if they notice?

a. temp 35.6(96.1)

A nurse and an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following indicates a need for hospitalization. a. Temp 35.6 C (96.1) b. HR 56/min c. Weight 10% below ideal weight d. Potassium 3.8 mEq/L

c. suicide potential.

A nurse assesses a client at a community mental health facility using the SAD PERSONS tool. The nurse knows that this tool provides which of the following data related to a client? A. Current anxiety level B. Problem-solving ability C. Suicide potential D. Mood disturbance

C. Insomnia

A nurse in a long-term care facility is assessing an older adult for depression. Which of the following findings should the nurse expect? a. Rapid mood swings b. sun downing c. insomnia d. rambling speech

b. the client has diabetes mellitus

A nurse in a mental health facility is assessing a client for suicide risk factors using the the SAD PERSONS scale. Which of the following indicates a risk suicide? a. The client is married b. The client has diabetes mellitus c. The client is 50 years of age d. The client is female

D. Monitor the client for escalating behavior.

A nurse in an acute mental health facility is caring for a client who is experiencing a mixed episode of bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step-by-step instructions during hygiene activities. D. Monitor the client for escalating behavior.

B. identify the client's perception of her mental health status.

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action? A. Respect the client's need for personal space. B. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder.

D. "My mother is currently on furosemide for her congestive heart failure."

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the highest priority to report to the provider? A. "My mother has diabetes that is controlled by her diet." B. "My mother recently completed a course of prednisone for acute bronchitis." C. "My mother received her flu vaccine last month." D. "My mother is currently on furosemide for her congestive heart failure."

A. Do you have a plan? B. Have you thought about hurting yourself? C. Do you feel that life is not worth living? E. Have you experienced a recent change in your mood?

A nurse is assessing a client who is suicidal. Which of the following is appropriate for the nurse to ask the client? (Select all that apply.) A. Do you have a plan? B. Have you thought about hurting yourself? C. Do you feel that life is not worth living? D. Why do you want to commit suicide? E. Have you experienced a recent change in your mood?

C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply.) A. Allow the child to choose consequences for negative behavior. B. Use role-playing to act out unacceptable behavior. C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior

A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply.) A. Allow the child to choose consequences for negative behavior. B. Use role playing to act out unacceptable behavior. C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

Tooth erosion. Hand calluses. Hypokalemia.

A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findings should the nurse identify as manifestations of bulimia vervosa? (Select all the apply.)

amenorrhea

A nurse is assisting with the collection of admission data for a client who has anorexia nervosa. The client has lost 11.4 kg over the past month and currently weighs 38.6 kg ( 85 lb). The nurse should expect which of the following findings?

30% weight loss or more in 6 months a temp of 96.8 or less (hypothermia) Potassium level less than 3 HR under 40

A nurse is caring for a client who has anorexia nervosa, which of the following criteria would support hospitalization.

a. disorganized speech

A nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of the following findings should the nurse expect? a. Disorganized speech b. Height concentration c. Hypersomnia d. Agoraphobia

d. lead the client outside for a walk

A nurse is caring for a client who has bipolar disorder the client is walking in and out of rooms, speaking appropriately, and giggling. Which of the following actions should the nurse take? a. Tell the client there will be negative consequences for her behavior b. Take the clients for the day room to watch a movie with other clients c. Have the client return to her room to read a book d. Lead the client outside for a walk

C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

A nurse is caring for a client who has bulimia nervosa and who has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following is an appropriate response by the nurse? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

A. Administer the next dose of lithium carbonate as scheduled.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the nurse notes that the lithium blood level is 1.2 mEq/L. Which of the following is an appropriate action by the nurse? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

D. "Ensure that the client swallows medication."

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 that the client swallows medication."

B. orthostatic hypotension

A nurse is caring for a client who is taking phenelzine (Nardil). For which of the following adverse effects should the nurse observe? (Select all that apply.) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Headache E. Bruxism

B. "we are concerned about you I need to keep you safe."

A nurse is caring for a client who is under observation for suicidal ideation's and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statement should the nurse make? a. "since you were trying to follow the treatment plan, we can submit your request to the provider" b. "we are concerned about you I need to keep you safe" c. "until your medication has reached therapeutic levels, you will need constant observation" d. "if you complete a contract that states you will not harm her self, you can be alone"

d. withhold the next dose of the medication

A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take? a. ask the client about a recent change in laundry detergent b. Explain that the medication causes a temporary rash c. Apply hydrocortisone cream on the clients rash d. Withhold the next dose of the medication

A. "Life isn't worth living if I gain weight."

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

B. Adolescents C. Native Americans D. Clients who have a depressive disorder

A nurse is conducting a class for a group of newly licensed nurses on identifying risk factors for suicide. Which of the following individuals should the nurse include as having the highest risk for suicide? (Select all that apply.) A. Older adult females B. Adolescents C. Native Americans D. Clients who have a depressive disorder. E. Clients who have hypomania

b. encourage physical activity for the client during the day.

A nurse is creating a plan of care for a client who is major depressive disorder. Which of the following intervention should the nurse include in the plan? a. Identify and schedule alternative group activities for the client b. Encourage physical activity for the client during the day c. Discourage the client from expressing feelings of anger d. Keep a bright light on in the clients room at night correct

D. the client might have a headache after treatment.

A nurse is developing a teach plan for family have an older adult client who's receive transcranial magnetic stimulation. Which of the following information to the nurse include in the teaching plan? a. The client is at risk for aspiration during treatment b. The client will experience a seizure during treatment c. The client require intubation after treatment d. The client might have a headache after treatment

B. Difficulty sleeping can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

B. Difficulty sleeping can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

C. The presence of manifestations for at least 2 years.

A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect?

A. Bullying of others B. Threats of suicide C. Law-breaking activities

A nurse is obtaining a health history from the parents of a 12- year-old client who has conduct disorder. Which of the following are expected findings? (Select all that apply.) A. Bullying of others B. Threats of suicide C. Law-breaking activities D. Narcissistic behavior E. Flat affect

A. Bullying of others B. Threats of suicide C. Law-breaking activities

A nurse is obtaining a health history from the parents of a 12-year-old client who has conduct disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Bullying of others B. Threats of suicide C. Law-breaking activities D. Narcissistic behavior E. Flat affect

B. Hypokalemia D. Slightly elevated body weight

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply.) A. Amenorrhea B. Hypokalemia C. Mottling of the skin D. Slightly elevated body weight E. Presence of lanugo on the face

B. Substance use D. Irritability E. Aggressiveness

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following is an expected finding? (Select all that apply.) A. Fear of being alone B. Substance use C. Weight gain D. Irritability E. Aggressiveness

B. Offer concise explanations C. Establish consistent limits E. Use a firm approach with communication

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following is appropriate for the nurse to include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client complaints E. Use a firm approach with communication

D. Psychomotor retardation

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines? a. Poor problem-solving skills b. Markedly neglected hygiene с. Significant weight loss d. Psychomotor retardation

A. "What is your relationship like with your family?" C. "Would you describe your current eating habits?" E. "Can you discuss your feelings about your appearance?"

A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions are appropriate for the nurse to include in the assessment? (Select all that apply.) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"

B. "I may feel drowsy for a few weeks after starting this medication."

A nurse is providing teaching to a client who has a new prescription for amitriptyline (Elavil). Which of the following client statements indicates understanding of the teaching?

B. Administer the medication in the morning. C. Monitor for weight loss while taking this medication. E. This medication blocks the blocking the synaptic reuptake of serotonin in the brain.

A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply.) A. An adverse effect of this medication is CNS depression. B. Administer the medication in the morning. C. Monitor for weight loss while taking this medication. D. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop. E. This medication blocks the blocking the synaptic reuptake of serotonin in the brain.

A. Seizures B. Agitation E. Irregular pulse

A nurse is teaching the parents of a child with a new prescription for imipramine (Tofranil) and his parents about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Seizures B. Agitation C. Photophobia D. Dry mouth E. Irregular pulse

D. Implement one-to-one observation during meal times.

A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions is appropriate to include in the client's plan of care? A. Allow the client to select preferred meal times. B. Establish consequences for purging behavior. C. Provide the client with a high-fat diet at the start of treatment. D. Implement one-to-one observation during meal times

A. Age of 35 years old B. Female gender C. History of chronic asthma D. Currently smokes Downloaded by: eboula18 | eboula18@yahoo.

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has clinical findings of depression. The client lives at home with her husband and two young children. She currently smokes and has a history of chronic asthma. The nurse should identify which of the following as risk factors for depression for this client? (Select all that apply.)

C. "I am aware that my PMDD causes me to have rapid mood swings."

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I will use light therapy 30 minutes a day to prevent further recurrences of PMDD." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

A. Placing the client on one-to-one observation

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following is the highest priority action by the nurse? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects

use a cognitive behavioral approach regarding fears for weight gain

what is appropriate in in planning the care of a patient with anorexia nervosa?

supporting client self-administration of medications

what is the priority for bipolar patient hospitalized in therapeutic milieu?

no, the client shouldn't be consuming less than 1200 calories/day but 2500 calories may be too overwhelming, provide the client with small frequent meals throughout the day.

while caring for a client with an eating D/O should you increase daily caloric intake to 2500 calories?