Mental Health Hesi

a women is brought to the psychiatric clinic by her husband who reports that his wife is reluctant to leave home because of what she describes as fear of open places & crowds. What is the best nursing diagnosis for this client?

Ineffective individual coping

The nurse on the evening shift received report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT?

Keep the client NPO after midnight

The nurse is performing intake interviews at a psychiatric clinic. Afemale client with a known history of drug abuse reports that she has a heart attack four years ago. use of which substance abuse places the client at highest risk for myocardial infarction

Methamphetamine

A male client with bipolar disorder has not slept or eaten in four days. he paces & becomes increasingly agitated & loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this time?

Move to a quiet area & provide peanut butter with crackers

The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?

Nausea & vomiting

A male client who is admitted with bipolar disorder (manic psychosis), is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping & screaming threats while having a plastic dinner knife. the client is given haloperidol (Haldol) 5mg IM STAT prior to seclusion. WHat intervention is most important for the nurse to implement immediately after seclusion?

Observe for extrapyramidal symptoms, such as Dystonia

the nurse completes a health assessment for a client a long alcohol dependency at the health finding is the client most likely to report?

Pancreatitis

A male college student brings his roommate to the campus clinic because the roommate has been talking to someone who is not present. the client tells the nurse that the voices are saying , "Kill Kill", What question should the nurse ask the client next?

"Are you planning to obey the voices?"

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! the other nurses dont care about me the way you do." which response is best for the nurse to provide this client?

"I am not the best nurse. All the nurses are good."

The nurse asks a female client with a borderline personality disorder, "How do you feel about your children not coming to visit this weekend?" The client looks out the window and replies, "I really dont care." which response is best for the nurse to provide?

"I noticed you were looking out the window when discussing your feelings"

a chronically depressed older male resident of a long-term care facility has become more reclusive & today refuses to leave his room. His family moved away from the local area & & they are unable to visit as much as they had in the past. Which commentby the nurse is like to be most helpful to this client?

"May I sit with you for a while?"

The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by client confirms this assessment?

"the nurse at night is trying to poison me with pills."

a 20-year old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states. " i am not going to take that medicine and you cant make me." What action should the nurse take?

Encourage the client to take the medicine because it will help her sleep

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia & medication adjustment of risperidone (Risperdal). When the client walks to the nurses station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

Administer the prescribed anticholinergic benztropine (Cogentin) for dsytonia

A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. the nurse notices needle marks on the clients arms & plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

Agitation, sweating, & abdominal cramps

The client is being admitted to the psychiatric unit for depression & self-deprecation. Which intervention should the nurse implement first?

Ask the client if he has plan to harm himself

A young adult female client is admitted to the psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the nighest priority?

Assess & report the clients electrolyte status to the healthcare provider

A client is admitted to the mental health unit & sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, & resists talking. What action should the nurse implement?

Attempt to ask the client simple questions

A client postpartum depression receive prescription Sertraline (Zoloft). What informoation is most important include in client teaching?

Contact health care provider suicidal ideation

The nurse notes that a depressed female client has been more withdrawn & no communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client

Encourage the client to participate in group activities

What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? the client will

Describe a decrease in anxiety using 1-10 anxiety scale

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Describe self as social drinker who drinks alcoholic beverages daily

An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. which assessment finding requires immediate follow-up?

Describes life as without purpose

A male employee who is assessed weekly in the employee clinic for blood pressure because of history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

Determine if the client has a weapon available for use

An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. which intervention should the nurse implement?

Direct the client to a new activity

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool?

Efforts to cut down, annoyance with question, quilt, drinking as an "eye-opener."

A young adult male client is admitted to the Psychiatric unit because of recent suicide attempt. His wife filed for divorce 6 months ago, he lost hsi job 3 months age, & his best friend moved to another city 2 weeks ago. Which intervention should the nurse include in the clients plan of care?

Encourage activities that allow the client to exert control over his enviroment

A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. the afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, & reports her findings to the nurse at bed time. what action should the nurse implement?

Encourage the client to express her feelings regarding the upcoming procedure

During the initial nursing interview, a client tells the nurse, " sometimes my thoughts go so fast. Wonder if i can sell my fast car. Work is so boring. I wonder if i can get a transfer. is it time to eat yet? Which documentation should the nurse use to describe the clients statement?

Exhibits tangential thinking

two days after his last drink, a male alcoholic client becomes agitated, & yells at his wife & children, "stay away from me!" His vital signs are elevated. What nursing diagnosis has the highest priority?

High risk for injury

The nurse interacts with a male client who is very depressed & slow to respond to questions. the nurse asks the client to explain how he feeling, but the client looks down at the table. What action would be best for the nurse to implement?

Return at a later time to talk

A 15-year-old male with mild mental retardation is admitted to the adolescent unit because he repeatedly refuses to complete personal hygiene the healthcare provider prescribes that the client brush his teeth 3 times a day. in the psychiatric team conference, a behavior modification program is recommended to engage the clients participation. When implementing this technique, what reinforcement is best for the nurse to provide?

Privilege restriction or fines for refusals to complete a hygiene task

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, what action should the nurse take?

Remove soft drink cans from the nurses desk & patient lounge

During a 1-1 session with the nurse, a female client who has been admitted for chronic depression & attempted suicide discloses her experience of sexual promiscuity & prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, "I dont remember, but my mother ran my father off when i was five." the nurse should recognize that the client may be using which defense mechanism?

Repression

A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?

Sublimation

When communicating a client Bipolar disorders, the nurse realizes that the client is suddenly becoming tense & verbally abusive. What action should the nurse take?

Suggest physical activity to the client such as taking a walk.

A client who refuses anti psychotic medications disrupts group activities, talks with nonsensical words & wanders into clients room. the nurse decides that the client needs constant observation based on which of these assessment findings?

Wanders into the clients rooms

A teenaged client, a herion addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

assess intake & output

A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the clients chief complaint in the medical record?

client states , "My date raped me tonight."

An female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse first take?

explore clients readiness to discuss the situation

When developing a plan of care for a client to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?

ineffective breathing patterns

The nurse is assess a male client with paranoia. Which behavior can this client be expected to?

is openly hostile the others for no apparent reason

A male client turns over a table in the dayroom of a psychiatric unit & threatens to throw a chair at another client. Which action is most important for the nurse to implement?

obtain staff assistance to help diffuse the escalating situation

An 8-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain for the family?

the drug that was ingested

the atypical anti-psychotic ziprasidone (Geodon) is prescribed for a client with a medical diagnosis of schizophrenia. after the client has been taking the medication for two weeks, the nurse assesses the drug's effectiveness. Which client report suggests that the medication is helpful?

the voices are quieter

A client is admitted to the mental health unit with a diagnosis of adjustment disorder& depressed mood. Findings of which diagnostic tests provide the most information for developing this clients plan of care?

urine drug screen