Mental Health Nursing- Mid-term Review Questions
A client comes to the emergency room. The client is profusely perspiring, breathing rapidly, and having dizziness and palpitations. Cardiac problems are assessed and ruled out. The client's diagnosis is a panic attack. The client states, "I thought I would die." What is the nurse's best response? A. "It was very frightening for you." B. "We would not have let you die." C. "I would have felt the same way." D. "But you are ok now."
A
A client is in a withdrawn catatonic state and exhibits waxy flexibility. During the initial phase of hospitalization for this client, the nurse's first priority is: A. watch for edema and cyanosis of the extremities B. encourage the client to discuss concerns that leads to the catatonic state C. provide a warm nurturing relationship with therapeutic use of touch D. identify the predisposing factors in the illness
A
A client perceives that her roommate's stuffed animal is her own dog at home. The nurse notes the client's misperception of reality is improving when the client says: A. Jan's stuffed dog looks somewhat like my dog B. Jan's dog and my dog could be twins C. I wish Jan had not had my dog stuffed D. I guess Jan needs a dog as much as I do.
A
A client reports becoming involved with legislation that promotes gun safety after the death of a child by accidental shooting. Which defense mechanism is the client exhibiting? A. sublimation (sublimation involves redirecting unacceptable feelings or drives into an acceptable channel) B. identification(Identification involves taking an attributes and characteristics of someone admired) C. denial(denial is the refuse to accept a painful reality by pretending that it did not happen ) D. intellectualization(Intellectualization involves excessive focus on reasoning to avoid feelings associated with a situation)
A
A client reports that men in blue clothes are looking in her window and talking about her. Which response by the nurse is most appropriate? A. Those men are groundskeepers. They are talking about their work, not you. B. Don't take things personally. Not everyone who is talking, is talking aboutyou. C. Let's not pay attention to the men. Let's play cards instead. D. Lets close the drapes so you can't see the men.
A
A client who has been stable on medications, comes to the clinic for a medication visit. The client suddenly jumps up, begins pacing, and wrings her hands. What should the nurse do first? A. walk with the client to help decrease anxiety B. ask the client about the sources of her anxiety C. discuss productive ways to solve problems causing anxiety D. share observations about her anxiety related behaviors
A
A client who is 30 years old has stopped her medication. She says God is telling me to protect myself. My friend says I smell from not showering and I don't sleep well. My parents are sick and tired of my illness and they wish I were dead. What should the nurse do first? A. Assess for suicidal or homicidal ideation B. Request order for toxic screens to detect medication levels C. Obtain orders to restart medications D. Contact the client's family
A
A client with diagnosis of Schizophrenia is withdrawn, unkempt, (unwashed and wearing unlaundered clothing) and unmotivatedto get out of bed. (Disheveled is another way we describe clients whose clothing is wrinkled, dirty, and not neatly arranged). A few staff new to the unit cannot understand why the anti-psychotic medication Fluphenazine has not had any effect on these symptoms for 10 days. The nurse's best response is: A. This medicine is most effective with positive symptoms of schizophrenia B. The client will be less withdrawn when this medication starts to work C. The client's medication needs to be increased to reduce these symptoms D. Lack of motivation is a common side effect of Fluphenazine.
A
A client with obsessive compulsive disorder reveals he is late for his appointment because of his "dumb habit." He has to take his socks off and put them back on 41 times. He can't stop until he does it right. The nurse interprets the client's behavior as representing what factor? A. Relief from anxiety B. Control of his thoughts C. Attention from others D. Safe expression of hostility
A
A client with panic disorderis taking alprazolam 1 mg. po three times daily. The nurse understands that this medication is effective in blocking symptoms of panic because it specifically acts on which neurotransmitter and increases its presence. A. Gamma-aminobutryrate B. Serotonin C. Dopamine D. Norepinephrine
A
A client with schizophrenia has been started on a medication therapy with clozapine (Clozaril, atypical antipsychotic).A nurse assess the results of which laboratory study to monitor for adverse effects from clozapine? A. White blood cell count B. platelet count C. blood glucose level D. liver function studies
A
A client's mother is having difficulty sleeping because she is worried that something will happen to her daughter if she leaves her alone. Her daughter has schizophrenia and has been home for 1 week. What problem is most important to incorporate in to the client's plan of care? A. caregiver strain B. anxiety C. fear D. Disturbed sleep pattern
A
A nurse is caring for a client with acute stress disorderwho is experiencing much anxiety right now. Which of the following statements by the nurse is most therapeutic? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life when you feel anxious." C. "Why do you believe you are experiencing anxiety?" D. "Let's discuss medications your provider is prescribing to decrease your anxiety."
A
A nurse is educating the client about prescription antidepressant medications and the appropriate expectations when taking these. Which statement by the nurse is accurate? A. it is important to continue taking antidepressants medication even after you feel better B. your symptoms will subside about 72 hours after starting the antidepressant medication C. the most potent antidepressant is fluoxetine ( Prozac) D. some common side effects of SSRIs are dry mouth, blurred vision, and urinary retention
A
A nurse is education a client diagnosed with depression who is experiencing insomnia. Which intervention should the nurse recommend to reduce episodes of insomnia? A. maintain regular bedtime hours B. sleep late on weekends to catch up on missed sleep C. fight insomnia when it occurs D. establish a regular exercise program a few hours before bedtime
A
An adolescent who is a junior in high school has a diagnosis of anxiety disorder. She would like to go away to college and believes she can handle it, but her parents worry that she will begin to have high anxiety again. They would like for her to attend a local community college. What should the nurse say in an outpatient counseling practice session? A. "Your parents have a point----- transitions have been hard for you in the past." B. "There are pros and cons here that we all need to discuss together." C. "Every high school graduate deserves the change to take on new challenges." D. "It may be premature for you to think of college at this point in time."
A
An experienced nurse is teaching a new nurse about establishing therapeutic relationship with client on a mental health unit. Which intervention should the nurse suggest when attempting to establish a therapeutic relationship with a client diagnosed with MDD? A. sit with the client with silence B. ask the client to join others to watch a 2-hour movie C. invite the client to attend an exercise class D. ask the client how their day should be scheduled
A
During a group session, a client who is depressed tells the group that he lost his job. which of the following responses by the nurse would be the best? A. It must have been very upsetting for you B. would you tell us about your job C. you will find another job when you are better D. you were probably too depressed to work
A
The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction but the the client does not respond to the nurse. which of the following responses by the nurse would be most appropriate? A. I will sit here with you for 15 minutes B. i will come back in a little bit later C. i will find someone else for you to talk D. i will get you something to read
A
The client says, I am being followed. They monitor my every move. It is not safe. The nurse will record this information under what heading? A. Thought content B. Quality of speech C. Insight D. Judgment
A
The nurse hands the medication cup to a client who is psychotic with concrete thinking. The nurse tells the client to take his medication. The client takes the cup and holds it in his hand. What should the nurse do next? A. Tell the client to put the medicine in the medicine in his mouth and swallow it with some water B. Instruct the client to sit in the dayroom and wait for the nurse to assist him C. Ask another staff member to stay with the client until the client takes the medication D. Say nothing and wait for the client to put the medication in their mouth and swallow it.
A
The veteran with post-traumatic stress disordertells the nurse about the destruction he witnessed during the war. He states "I killed all those people for nothing!" Which response by the nurse is the most appropriate? A. "You did what you had to do at the time." B. "Maybe you did not kill as many people as you think." C. "How many people did you kill?" D. "War is a terrible thing."
A
When developing the teaching plan for the family of client with severe depression who is to receive ECT which of the following would the nurse include? A. Some temporary confusions and disorientation immediately after the treatment is common B. During an ECT treatment session the client is at risk for aspiration C. Clients with severe depression usually do not respond to ECT D. The client will not be able to breathe independently during the treatment
A
A nurse is assessing a client with suspected major depression. Which findings would support a diagnosis of major depression? Select all that apply A. loss of interest or pleasure nearly daily for at least 2 weeks B. presence of psychomotor agitation nearly daily for at least two weeks C. feelings of worthlessness nearly daily for at least two weeks D. having a depressed mood nearly daily for at least 2 weeks E. talking rapidly with pressured speech nearly daily for at least two weeks F. impaired concentration nearly daily for at least two weeks
A, B, C, D, F
A client diagnosed with major depressive disorder has the nursing diagnosis of disturbed sleep pattern. When developing a plan of care for this client which nursing actions are more appropriate? select all that apply A. determine sleep patterns prior to hospitalization B. discourage sleeping during the day C. record and limit caffeinated drinks D. reinforce reality thinking E. encourage measures that aid in relaxation
A, B, C, E
A nurse is assessing a client with generalized anxiety disorder. Which of the following findings should the nurse expect to find? SELECT ALL THAT APPLY: A. Excessive worry for 6 months B. Impulsive decision making C. Restlessness D. Need for reassurance
A, C, D
A client with anxiety disorderis prescribed diazepam (valium) while the SSRI anti-depressant become effective (takes 3-4 weeks). Which instructions should the nurse give to the client. SELECT ALL THAT APPLY: A. Consult with his health care provider before he stops the medication B. Avoid eating cheeses and other foods with tyramine C. To take medication on an empty stomach D. Not to use alcohol while taking this medication E. Stop taking this medication if he experiences swelling of the lips and difficulty breathing
A, D
A client diagnosed with major depression spends the majority of the day lying in bed with the sheet pulled over his head . Which of the following approaches by the nurse would be most therapeutic? A. Wait for the client to start the conversation B. initiate verbal contact with the client frequently especially during patient checks C. sit outside the client's room D. question the client until he responds
B
A client diagnosed with schizophrenia has been hospitalized for 2 days and still believes his food is poisoned. The client's partner is asking how he can still be paranoid after being in the hospital for 2 days. What does the nurse accurately conclude? A. The wife's inquiry is reasonable B. Education about her husband's medication is needed C. Her expectations of her husband are realistic D. An increase in the client's medications is indicated
B
A client is pacing and wringing his hands. He answers, "I just need to walk," when the nurse asks what he is feeling. Which response by the nurse is most therapeutic? A. "You need to sit down and relax." B. "Are you feeling anxious?" C. "Is something bothering you?" D. "You must be experiencing a problem now."
B
A client is receiving Paroxetine (Paxil) 20 mg everyday. After taking the first three doses the client tells the nurse that the medication upsets his stomach. Which of the following instructions would the nurse give to the client? A. Take the medication hour before eating B. Take the medication with some food. C. take the medication at bedtime D. take the medication with 4 ounces of orange juice.
B
A client on Haloperidol (Haldol) is complaining of restlessness and internal jumpiness. Which medicine should the nurse administer to reduce these symptoms? A. Lorazepam (Ativan) B. Benztropine (Cogentin) C. Trazodone (Desyrel) D. Olanzapine (Zyprexa)
B
A client receiving tricyclic antidepressants arrives at the mental health clinic. which observation would indicate that the client is following medication plan correctly? A. client reports not going to work for this past week B. client arrives clinic neat and appropriate in appearance C. client complain of not bong able to do anything anymore D. client is sleeping for 12 hours per night and 3-4 hours during day
B
A client sitting off in a corner of the day room has his head tilted to one side as if listening to someone. The nurse suspects auditory hallucinations. What should the nurse ask first? A. Are you seeing someone other than me? B. What are you hearing right now? C. What is going on with you right now? D. Do you want to go to the recreation room now?
B
A client states that she hears God's voice telling her that she has sinned and must punish herself. What is the most important response that the nurse should offer? (command hallucinations- so we always ask what are the voices saying? Are the voices telling you to harm yourself? Then ask what are the voices telling you to do?) A. How do you think you will be punished? B. Do you think you need to punish yourself now? C. What exactly do you think you have done to be punished? D. Let's talk about your strengths.
B
A client who has had three episodes of recurrent endogenous depression within the past two years states to the nurse "I want to know why I am so depressed.' Which of the following statement by the nurse would be most helpful? A. I know you will get better with the right medication B. lets discuss possible reason underlying your depression C. your depression is most likely cause by a brain chemical imbalance D. members of your family seem very supportive of you
B
A client with anxiety disorder becomes anxious when touching fruit and vegetables. What should the nurse do? A. Instruct the client to not touch these items. B. Ask the client why she becomes anxious in this situation C. Assist the client to arrange for her family to do the food shopping D. Teach the client cognitive behavioral therapyapproaches to manage her anxiety
B
A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication , a nurse 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
B
A neatly dressed client clutches a brief case and backs away from the window in the admssions room. The client asks the nurse to move away from the window. The nurse will not follow this request because: A. the action will humor the client B. the action would indicate that the nurse agrees with the client's false ideas C. the client will feel he can always get his way D. the nurse will be demonstrating a lack of composure
B
A nurse is assessing a client with dysthymia who reports symptoms of depressed mood. Which assessment finding supports the essential feature of dysthymia? A. recurrent thoughts of death B. chronically depressed mood for most of the day for at least 2 years C. significant weight loss D. diminished ability to think or concentrate
B
A nurse is describing the medication side effects to a client who is taking oxazepam (Serax). the nurse incorporates in discussion with the client the need to: A. consume a low fiber diet B. include fluids and bulk in the diet C. rest if heart start to beat rapidly D. take antidiarrheal agents if diarrhea occurs
B
A nurse is performing a follow up teaching session with a client discharged 1 month ago. the client is taking fluoxetine (Prozac) what information would be important? A. cardiovascular symptoms B. gastrointestinal dysfunctions C. problems with dryness D. problems with excessive sweating
B
A nurse is reviewing diet restrictions with a client taking a MAOI. Which symptom may occur with nonadherence to diet restrictions while taking MAOI? A. Agranulocytosis B. explosive occipital headache C. severe hypotension-read carefully-nclex also offers these answers D. akathisia
B
A nurse is teaching a client who is starting on imipramine (Tofranil). The nurse tells the client that the maximum desired effect may: A. start during the first week of administration B. not occur for 2-3 weeks of administration C. start during the second week D. not occur until after two months
B
A nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacingas she watches television. the client is experiencing A. parkinsonism B. tardive dyskinesia C. hypertensive crisis D. neuroleptic syndrome
B
A pregnant client is prescribed Chlorpromazine 25 mg 4 times per day. What are the most important instructions to include in the client's teaching plan? A. Don't drive because there is a possibility that you will have seizure B. Avoid going out in the sun without sunscreen C. Stop the medication if constipation occurs D. Tell your health care provider if your blood pressure increases
B
A young client with paranoid schizophrenia tells the nurse ' I thought everyone was out to get me and I stayed inside all the time. Now I would like to go out and do things again." What is the best initial response by the nurse? A. with whom do you want to do things? B. what activities did you enjoy in the past? C. what kind of transportation do you use? D. how much money can you spend?
B
During an interaction with the nurse , a client states,' My husband has supported me every time I have been hospitalized for depression. He will leave me this time. I am an awful mother and wife." Based on this information which of the following nursing diagnosis would the nurse identify when developing the client's plan of care? A. Impaired social interaction related to unsatisfactory relationship as evidenced by withdrawal B. low self esteem related to lack of self worth as evidenced by negative self statements C. risk of self directed violence related to feeling of guilt as evidenced by statements of suicide ideation D. ineffective coping related to hospitalization as evidenced by impaired judgement
B
The client diagnosed with conversion disorder has a paralyzed arm. A staff member states " I could just tell the client that he arm is paralyzed because she had an affair and neglected her baby''s care to the point where the baby had to be hospitalized for dehydration." Which response by the nurse is best? A. "Ignore the client's behaviors and treat her with respect." B. "Pushing insight will increase the client's anxiety and need for physical symptoms" C. "Pushing awareness will be helpful and further the client's recovery." D. "We will meet with the client and confront her behavior."
B
The client has somatization disorder involving nausea. He says the nausea began when his wife asked him for a divorce. In the past, this client has had problems with back pain, chest pain and difficulty urinating. No medical diagnosis was established for these. Which intervention is most appropriate by the nurse? A. Ask the client to describe his problem with nausea. B. Direct the client to describe his feelings about his impending divorce. C. Ask the client to talk about the healthcare providers he has seen and the medications he has taken. D. Inform the client about a different medication for his nausea.
B
The client says she is being followed by foreign agents. Which response by the nurse is most appropriate here? A. I don't see the foreign agents B. I think these thoughts are frightening to you C. I don't know what you mean D. I would like you to come to group with me right now.
B
The parents of a 20 year old client with paranoid schizophrenia attended a family education group. What statement by the client's mother indicates she understands her daughter's illness and management? (choose the best answer) A. I know that I have to do everything for her when she gets home B. Tasks as simple as getting out of bed and showering may be difficult for her C. I know that visits from her friends at home should be discouraged for a while. D. She won't experience a relapse as long as she takes her medication.
B
The physician orders fluoxetine (Prozac) orally every morning for a 72 year old client with depression. The nurse would expect the physician to order which of the following dosages for the client? A. 0.5 mg B. 10 mg C. 25 mg D. 30 mg
B
A nurse is meeting with the client who is being discharged after hospitalization for suicidal ideation. Based on knowledge of expert consensus of warning signs for suicide, the nurse should plan to advise the client to seek help by contacting a mental health professional or calling the national suicide prevention hotline if experiencing: select all that apply: A. sadness (sadness can be a normal mood variation) B. hopelessness C. severe anxiety and agitation D. feeling of being trapped E. increasing alcohol or drug use
B, C, D, E
If I touch someone without permission in a non-emergency situation in psychiatric nursing, what is the legal term for that action?
Battery
A 22 year old client is being admitted with a diagnosis of brief psychotic disorder. Which finding would the nurse expect to find during the admission interview that is consistent with the client's diagnosis? A. Current treatment for pneumonia B. Regular use of alcohol or marijuana C. Evidence of delusions or hallucinations D. History of chronic depression
C
A 62 years old female client with severe depression and psychotic symptoms is scheduled for electroconvulsive therapy (ECT) tomorrow morning. The client's daughter asks the nurse," How painful will the treatment be for mom?" The nurse would correctly respond her by saying which of the following? A. Your mother will be given something for pain before treatment B. the physician will make sure your mother does not suffer needlessly C. your mother will be asleep during the treatment and will not be in pain D. your mother will able to talk to us and tell us if she is in pain
C
A client is newly prescribed tramadol hydrochloride (Ultram) for chronic pain. The client is also taking fluoxetine (Prozac) 40 mg daily for depression. Which statement by the nurse accurately explains the interactions between the two drugs? A. there is no major concern with this drug combination B. tramadol hydrochloride may decrease the effectiveness of fluoxetine C. this drug combination can increase the risk of serotonin syndrome D. SSRIs should not be taken within 14 days of the last dose of tramadol hydrochloride
C
A client is remaining in his room because he believes that the staff want to harm him. What care plan outcome is most realistic? A. Within 2 days, client will completed activities of daily living B. Within 3 days the client will participate in recreation with other clients C. Within 4 days, the client will demonstrate an absence of verbal aggression D. Within 5 days the client will seek out staff to talk about feelings
C
A client reports becoming physically ill with frequent crying spells , intense feelings of worthlessness , and loss of appetiteon the anniversary of the death of the client's spouse.The client report this has occurred for the last five years. Based on the report symptoms, what should a nurse conclude that the client is experiencing? A. uncomplicated grief (In uncomplicated grief, the client's self esteem remains intact with symptom resolution) B. delayed grief reaction ( Delayed grief reaction is the absence of the expression of grief during situations when a grief reaction is expected) C. distorted grief reaction( The nurse should determine that the client is experiencing a distorted grief reaction. The symptoms reported by the client are exaggerated and prolonged) D. depression (a depression disorder is a form of an exaggerated or distorted grief response)
C
A client who has been diagnosed with schizophrenia as well as chronic alcohol dependence has been taking risperidone for several months. She stopped drinking 4 days ago and is seeing and feeling bugs crawling under her skin. Which factor must the nurse include in the plan of care when explaining visual and tactile hallucinations? A. Alcohol intoxication B. Ineffectiveness of risperidone C. Alcohol withdrawal D. Interaction of alcohol and risperidone
C
A client who is receiving amitriptyline (Elavil) 150 mg daily is scheduled for surgery. Which statement reflects accurate understanding of safety concerns in this situation? A. client should be switched to doxepin (sinequan) instead of amitriptyline B. amitriptyline should be continued as the stress of surgery will worsen depression C. Amitriptyline can cause hypertensive episodes during surgery D. amitriptyline can be safely reduced to 100 mg daily rather than discontinuing it
C
A client who is threatening to kill her ex-husband is brought to the ED. Her ex-husband is in treatment and has a case manager. The nurse will first assess the client's risk for self harm and harm to others and then do which intervention next? A. obtain the name of the husband's case manager B. ask about marital problems leading to her divorce C. interview the client about her current needs and situation D. ask to speak with the client's ex-husband
C
A client who is well known in the community as a scholarship winner tells the nurse that he hears voices that tell him he is worthless. He has attempted suicide. What statement should the nurse say first to establish a therapeutic relationship with the client? A. you have a lot to live for B. the voices are not real C. I'm sorry this is happening to you D. would you like me to call your parents?
C
A nurse is establishing a plan of care for a client scheduled for ECT. which planned action by the nurse is unsafe when caring for this client? A. administering a short acting barbiturate prior to the procedure B. monitoring vital signs before during and after the procedure C. administering succinylcholine after the procedure to decrease recovery time D. educating the client that experiencing confusion tiredness, headache , muscle pain or back pain after the procedure is normal
C
The client says "the aliens are telling me that I am defective and I need to be eliminated." Which response by the nurse is most appropriate initially? A. I know those voices are real to you, but I do not hear them. B. You're having hallucinations as a result of your illness. C. I want you to agree to tell staff when you hear these voices D. Your medications will help control these voices you are hearing.
C
Which of the following statements by the client taking trazodone (Desyrel) as prescribed by the physician indicated to the nurse that further teaching about the medication is needed? A. I will continue to take my medication after a light snack B. taking desyrel at night help me to sleep C. my depression will be gone in 5 to 7 days D. i will call my doctor if i start to have flu symptoms
C
Which nursing diagnosis should a nurse give highest priority when caring for a client with major depressive disorder? A. powerlessness B. potential for spiritual distress C. potential for injury D. disturbed sleep patterns
C (The potential for suicidal behavior is the highest priority for clients diagnosed with major depressive disorder.)
A client is being discharged after hospitalization for a suicide attempt. Which question asked by the nurse assess the learned prevention and future coping strategies of the client? A. "how did you try to kill yourself? B. do you have the phone number of the suicide prevention center? C. what skills can you utilize if you experience problem again? D. why did you think life was not worth living?
C (asking the client directly regarding what skills he or she could utilize if similar problems occurred in the future provides the client with an opportunity to reflect on learned behaviors and to determine a plan for future prevention)
A nurse is interviewing a client at a mental health clinic. Which care setting should the nurse determine is most appropriate for the client who recently attempted suicide and continues to report suicidal ideation? A. an outpatient clinic B. a community mental health center C. an inpatient mental health unit D. a nursing home
C (because this unit have equipped to handle the safety issues of risky behaviors)
A nurse is planning care for a client diagnosed with acute mania. What situation must occur prior to initiating treatment with lithium carbonate? A. room seclusion has proven ineffective in controlling the client's behavior B. the client has been fasting for 12 hours C. the client's history and physical results, including laboratory results are reviewed D. administration of benzodiazepine has been terminated
C (the use of lithium carbonate requires initial and ongoing health assessment and laboratory monitoring. Because lithium is excreted by the kidneys, a baseline evaluation has to be completed before treatment begins. it can take up to a week for lithium to be effective) (room seclusion is used as a last resort and is unrelated to medication administration)
A client has an Axis I diagnosis of major depression. Which of the following features would be most crucial for the nurse to assess? A. sleep disturbance B. feelings of worthlessness C. difficulty with concentration D. suicidal ideation
D
A client is scheduled for discharge and will be taking phenobarbital (Luminal) for an extended period. A nurse would place highest priority on teaching the client which of the following points that directly related to the client safety? A. take the medication only with the meals B. take the medication at the same time each day C. use a dose container to help prevent missed dose D. avoid drinking alcohol while taking this medicine
D
A client recently diagnosed with depression tells a nurse that she is 2 months pregnant and is reluctant to take an antidepressant medication. The client ask what other treatment options are available. Which type of therapy should a nurse recommend as an alternate treatment for depression? A. client centered therapy B. gestalt therapy C. therapeutic touch therapy D. cognitive behavioral therapy
D
A client who is depressed states,"I am an awful person. Everything about me is bad. I cannot do anything right." Which of the following responses by the nurse would be most therapeutic? A. Everybody around here likes you B. I can see many good qualities in you C. lets discuss what you done correctly D. you were able to bathe today
D
A client with generalized anxiety disorderis given a prescription for Venlafaxine. What information does the nurse include in the teaching plan for the client? A. Various strategies for reducing anxiety B. The benefits and actions of venlafaxine in treating GAD C. How venlafaxine will reduce anxiety at home and at work D. The management of common side effects of this medication E. Substituting adaptive coping strategies for maladaptive ones F. The positive effects of venlafaxine being evident in 4- 5 days.
D
A client with sleep disturbances feelings of worthlessness, fatigue and inability to concentration was let go from her place of employment a month ago. While interacting with the nurse, the client states "My boss was wonderful! he was understanding and a really nice man." The nurse interprets this statement as indicating which of the following defense mechanism? A. repression B. suppression C. intellectualization D. reaction formation
D
A male client who is very depressed exhibits psychomotor retardation , a flat affect and apathy. The nurse observes the client to be in need of grooming and hygiene. which of the following nursing action would be best? A. explaining the importance of hygiene to the client B. asking the client if he is ready to shower C. waiting until the client family participate in the client care D. stating to the client that it is time for him to take shower
D
A newly admitted client is on a mission to save her son by eliminating "provocative sluts" of the world. There are many attractive young women on the unit now. What should the nurse do first? A. ask the client to define provocative B. discuss dress code with all clients in the next community meeting C. have a client discuss her concerns in the next group meeting D. ask the client to inform the staff if she has negative thoughts about other clients
D
A nurse is administering risperidone (Risperdal) to a client who is scheduled to be discharged. Before discharge, which of the following should the nurse include in the teaching? A. get adequate sunlight B. avoid foods rich in potassium C. continue driving as usual D. get up slowly when changing position
D
A nurse is interpreting the serum laboratory report for a client in an emergency department. The history and reports reveal that the client has been diagnosed with bipolar disorder and receive lithium carbonate. Based on the findings of the serum laboratory report, which result would explain the client's condition of impaired consciousness, nystagmus, and seizures? lab test Client's value normal range Creatinine 0.8 mg/dl 0.5-1.5 mg/dl BUN 10 mg/dl 5-25 mg/dl Na 140 mEq/L 135-145 mEq/L lithium 3.8 mEq/L 0.5-1.2 mEq/L A. creatinine B. BUN C. Na D. Lithium
D
After few minutes of conversation a female client who is depressed wearily asks the nurse 'why pick me to talk to? Go talk to someone else." Which of the following response by the nurse would be best? A. I am assigned to care for you today, if you will let me. B. You have a lot of potential, and i would like to help you C. i will talk to someone else later D. I am interested in you and i want to help you.
D
An adolescent has panic attacksat school. He is concerned about leaving home and going away to college. He is missing some classes because of his symptoms. What is the best response of the school nurse who has been helping him with the panic attacks? A. "It's natural to be worried about going into a new environment. I'm surewith your abilities you'll do wellonce you get settled." B. "You're putting too much pressure on yourself. You need to relax more. Things will be all right." C. "It might be bestto postpone going to college. You need to get these panic attacks under control." D. "It sounds like you have a real concern about transitioning to college. Let's work with a therapist who specializes in treatment of panic disorder."
D
The client diagnosed with agoraphobia refuses to walk down the hall to the group room. Which response by the nurse is the most appropriate? A. "I know you can do it." B. "Try holding onto the wall as you walk." C. "You can miss group this one time." D. "I will walk with you."
D
The client diagnosed with fear of eating in public (social phobia) has finished eating lunch in the dining area with other clients. Which statement by the nurse reinforces this positive behavior? A. "It wasn't so hard, now, was it?" B. "At supper, I hope to see you eat with a group of people." C. "You must have been hungry today." D. "It's progress for you to eat with others in the dining room."
D
When preparing the teaching plan for a client to begin taking clozapine, what information is crucial to include? A. A description of akathisia and drug induced parkinsonism B. Measure to relieve episodes of diarrhea C. The importance of reporting insomnia D. Emphasize that they will need to have their blood drawn weekly.
D
A client jumps when spoken to and report feeling uneasy. The client states, "It is as if something bad is going to happen." What should the nurse do from first to last? A. Teach problem solving techniques B. Ask the client to deep breathe for 2 minutes C. Discuss the client's feelings in more depth D. Reduce environmental stimuli.
D, B, C, A
What is the safest position to place a patient when in four point restraints?
Supine
What is the least restrictive treatment that the nurse gives?
Talking
Who assesses the patient and signs the restraint documentation every 30 minutes during a patient restraint?
The RN
What staffing is necessary for a patient in restraints?
There must be a staff member always present, and every 30 min an RN assesses a pt on restraints
List what is assessed during a 15-minute assessment check on a restrained or secluded patient?
VS, level of consciousness, skin assessment, pulses of the extremities
When must a restraint order from a psychiatrist be obtained?
Within 1 hour
What is section 35?
a person with alcohol or substance abuse, committed, for 30 days, can be renewed
What is a section 8?
long term involuntary
What is the section number of short term involuntary commitment?
section 12
Can psychotic section 8 patients who are hallucinating refuse their medication in a treatment setting?
yes
Must mental health staff remain with a patient who is in restraints or in seclusion or both- at all Times?
yes for both
Can a registered nurse begin a restraint and if so under what circumstances?
yes. If a patient is being harmful to themselves or others or is threatening to do so, and we tried every other measure
What is a Section 8B?
you can medicate people involuntary by court
