Mental Health Nursing (Unit 2 Exam)
Electroconvulsive therapy (ECT) is used as an effective treatment for which mental disorders (select all that apply)? 1. Depression 2. Severe catatonia 3. Mania 4. Schizophrenia
1, 2, 3, & 4
A nurse is caring for a client who is undergoing a major life crisis. Which self-care concepts should the nurse teach the client to enhance the client's ability to cope with the stress (select all that apply)? 1. Teach the client the exercise can be a healthy coping mechanism 2. Teach the client that hitting others, hurting oneself, and destroying property can be effective coping mechanisms 3. Teach the client to control anger by counting to 10 and breathing deeply 4. Teach the client to divert his or her attention to another task
1, 3, & 4
For the past 5 days, a client has been receiving tranylcypromine sulfate (Parnate) 10 mg PO BID for treatment of a major depressive episode. This morning, the client refuses the medication, stating, "It doesn't help, so what's the use of taking it?" The response by the nurse that would best demonstrate an understanding of the action of this monoamine oxidase inhibitor (MAOI) would be: 1. "Sometimes it takes 2-4 weeks to see an improvement." 2. "It takes 6-8 weeks for this medication to have an effect." 3. "You should have felt a response by now. I'll notify your provider." 4. "I'll talk tot he physician about increasing the dosage, and that will help."
1. "Sometimes it takes 2-4 weeks to see an improvement."
The statement that would be most appropriate for the nurse to use in interviewing a newly admitted, 35-year-old, depressed client whose thoughts focus on feelings of unworthiness and failure would be: 1. "Tell me how you feel about yourself." 2. "Tell me what has been bothering you." 3. "Why do you feel so bad about yourself?" 4. "What can we do to help you during your stay with us?"
1. "Tell me how you feel about yourself."
A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group? 1. "The leader is a nurse or psychiatrist." 2. "The members provide support to each other." 3. "People who have a similar problem are able to help others." 4. "It is designed to serve people who have a common problem."
1. "The leader is a nurse or psychiatrist."
When developing a plan of care for a depressed client, the approach that would be most therapeutic would be: 1. Allowing time for the client's slowness when planning activities. 2. Helping the client focus on family strength and support systems. 3. Encouraging the client to perform menial tasks to meet the need for punishment. 4. Repeating again and again that the staff views the client as worthwhile and important.
1. Allowing time for the client's slowness when planning activities.
A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing? 1. Denial 2. Projection 3. Regression 4. Rationalization
1. Denial
The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nurse intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client.
1. Initiate confinement measures.
What is the priority nursing concern when a client is in a state of panic? 1. Maintenance of client safety 2. Identification of the precipitating factor 3. Preventing escalation of symptoms 4. Provision of privacy
1. Maintenance of client safety
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the client 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 to calm down in and gain control.
1. Provide safety for the client and other clients on the unit.
Neuroleptics are the drugs of choice to relieve the symptoms of: 1. Psychosis 2. Depression 3. Hyperkinesis 4. Narcotic withdrawal
1. Psychosis Rationale: The neuroleptics modify the behavior of psychotic clients so they can cope more effectively with the environment and benefit from therapy.
The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer anti-anxiety medication. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.
2. Examine and treat the wound sites. Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerates wrists can lead to a life-threatening situation. Other interventions may follow after treating the client medically.
An activity that would be most appropriate for a depressed client during the early part of hospitalization would be a: 1. Game of Trivial Pursuit 2. Project involving drawing 3. Small dance-therapy group 4. Card game with three other clients
2. Project involving drawing
A withdrawn client refuses to get out of bed and becomes upset when asked to do so. What nursing action is most therapeutic? 1. Requiring the client to get out of bed 2. Staying with the client until the client calms down 3. Giving the client the PRN antipsychotic that is prescribed 4. Leaving the client alone in bed for as long as the client wishes
2. Staying with the client until the client calms down
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping-pong 4. Basketball
2. Writing
During a group meeting, a male client tells everyone of his fear of his impending discharge from the hospital. It would be most appropriate for the group leader to respond: 1. "You ought to be happy that you're leaving." 2. "Maybe you're not ready to be discharged yet." 3. "Maybe others in the group have similar feelings that they would like to share." 4. "How many in the group feel that this member is ready to be discharged?"
3. "Maybe others in the group have similar feelings that they would like to share."
A client with a diagnosis of depression has been hospitalized on a psychiatric unit for 1 week. When scheduling activities for this client, it would be most appropriate to plan for the client to: 1. Complete a jig-saw puzzle by herself 2. Play a game of cards with several other clients 3. Talk with the nurse several times during the day 4. Engage in a game of ping-pong with another client
3. Talk with the nurse several times during the day
As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, she says, "I have nothing to talk about." What is the best response by the nurse? 1. "Maybe tomorrow you will feel more like talking." 2. "Could you start off by talking about your family?" 3. "A person like you has a great deal to offer the group." 4. "You feel you will not be accepted unless you have something to say?"
4. "You feel you will not be accepted unless you have something to say?"
The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all client experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What would be important to maintain safety of the client during the 6-week treatment program? 1. Tyramine-free meals 2. Avoidance of exposure to the sun 3. Maintenance of a steady sodium intake 4. Elimination of benzodiazepines for nighttime sedation
4. Elimination of benzodiazepines for nighttime sedation Rationale: The use of these drugs can raise the seizure threshold, which would be counterproductive.
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that now others need a chance to contribute.
4. Thank the client for the input, but inform the client that now others need a chance to contribute.
Grief associated with impending death or loss is called ____________________ _____________.
anticipatory grief
A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom. I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they do." Which of these problems should the nurse focus on first? a. Risk for violence. b. Delusions of grandeur. c. Disturbed personal identity. d. Risk for noncompliance.
b. Delusions of grandeur.
The most advantageous therapy for a preschool-age child with a history of physical and sexual abuse would be: 1. Play 2. Group 3. Family 4. Psychodrama
1. Play
After several weeks of caring for a client in the terminal stage of an illness, the nurse becomes increasingly aware of a need to get away from the relationship for a period of time. The best initial action by the nurse would be to: 1. Ask to be assigned to another client 2. Request vacation time for a few days 3. Seek support from colleagues on the unit 4. Withdraw emotional involvement from the client
3. Seek support from colleagues on the unit
A client with diabetes is able to discuss in great detail the metabolic process in diabetes while eating a piece of chocolate cake topped with butter frosting. This is an example of the defense mechanism known as: 1. Projection 2. Dissociation 3. Displacement 4. Intellectualization
4. Intellectualization
During a special meeting to discuss the unexpected suicide of one of the female clients while on a weekend pass, the nurse overhears another client moan softly, "I'm next. Oh my gosh, I'm next. They couldn't prevent hers and they can't protect me." It would be most therapeutic for the nurse to respond by saying: 1. "You are afraid you will hurt yourself?" 2. "The other client was a lot sicker than you." 3. "It's different. The other client was home; you are here." 4. "There is no need to worry. Passes will be cancelled for a while."
1. "You are afraid you will hurt yourself?"
The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task is most appropriate for this phase? 1. Planning short-term goals 2. Making appropriate referrals 3. Developing realistic solutions 4. Identifying expected outcomes
2. Making appropriate referrals
During individual sessions designed to help the depressed client with a history of suicide attempts explore alternative coping strategies, it would be most appropriate for the nurse to ask: 1. "How have you managed your problems in the past?" 2. "What do you feel you have learned from this suicide attempt?" 3. "How will you manage the next time your problems start piling up?" 4. "Were there other things going on in your life that made you want to die?"
3. "How will you manage the next time your problems start piling up?" Rationale: This question focuses the interaction toward the future and invited the client to explore alternative coping strategies.
A widow of 10 days says to the nurse from hospice who has called to invite her to a grieving support group meeting, "I feel like I am losing my mind. I see my husband in the house, in the yard, sometimes even at the store. I even find myself talking to him about things that happen." Which is the best response for the nurse to make? 1. "If these things are still going on in 23 months then you may need to worry about losing your mind, but you don't need to worry now. 2. "That is a concern. Tell me more about what is going on with you." 3. "I understand you find these events very disturbing but they are normal parts of the grieving process." 4. "You need to relax; things will improve with time."
3. "I understand you find these events very disturbing but they are normal parts of the grieving process." Rationale: These are normal responses to grief. Although option 2 is therapeutic, it's incorrect because the events are normal and not a cause for concern.
The nurse employed in a mental health unit of a hospital is a leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development? 1. Acknowledging that the group has identified goals. 2. Encouraging the accomplishment of the group's work. 3. Acknowledging the contributions of each group member. 4. Encouraging members to become acquainted with one another.
3. Acknowledging the contributions of each group member.
A long-term therapy goal for a female client hospitalized for a major depressive episode should be that the client will be: 1. Able to talk about her depressed feelings 2. Able to develop new defense mechanisms 3. More realistic in accepting herself and others 4. Awareness of the unconscious source of her anger
3. More realistic in accepting herself and others
A description of displacement is: 1. Imaginative activity to escape reality 2. Ignoring unpleasant aspects of reality 3. Resisting any demands made by others 4. Pent-up emotions directed to other than the primary source
4. Pent-up emotions directed to other than the primary source
Antidepressant medications must be prescribed and administered with care, particularly when being given to elderly clients. Which adverse effects should the nurse anticipate when administering antidepressants to elderly clients (select all that apply)? 1. Anticholinergic effects 2. Cardiac effects 3. Agitation 4. Hostility
1 & 2
Clients who experience psychosocial crisis are at risk for suicide. Which are additional risk factors for suicide (select all that apply)? 1. Younger than 20 years of age 2. Older than 45 years of age 3. Severe, intractable pain 4. Substance abuse
1, 2, 3, & 4
Clients with histories of which of the following factors are at increased risk for committing suicide (select all that apply)? 1. Substance abuse 2. Impulsiveness 3. Intractable, severe pain 4. Family history of child abuse 5. Altered body image
1, 2, 3, 4, & 5
When caring for a client on suicide precautions, which items should the nurse remove from the room (select all that apply)? 1. Hand mirror 2. Nail file 3. Aerosol deodorant 4. Alcohol based mouth wash 5. Nail polish remover 6. Matches
1, 2, 3, 4, 5, & 6
The nurse in the mental health unit recognizes which as bring therapeutic communication techniques (select all that apply)? 1. Restating. 2. Listening. 3. Asking the client, "Why?" 4. Maintaining neutral responses. 5. Providing acknowledgment and feedback. 6. Giving advice and approval and disapproval.
1, 2, 4, & 5
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence. 2. Sharing personal preference regarding food choices. 3. Documenting reasons why the client does not want to eat. 4. Offering opinions about the necessity of adequate nutrition.
1. Using open-ended questions and silence.
A 30-year old woman is brought to the local community hospital by a family member because the woman "has been acting strange." When assessing this client, which statements would meet involuntary hospitalization criteria (select all that apply)? 1. "I cry all the time, I am so depressed." 2. "I would like to end it all with sleeping pills." 3. The voices say it is okay for me to kill all prostitutes." 4. "My boss is always picking on me and it makes me angry."
2 & 3
A psychiatric nurse is caring for a client who is involved in an emotionally abusive relationship. The nurse knows the the client may be at risk for which disturbances in self-concept (select all that apply)? 1. Disturbed body image 2. Low self-esteem 3. Ineffective role performance 4. Disturbed personal identity
2 & 4
A client is admitted to the mental health unit with the diagnosis of bipolar disorder, depressed. During the assessment interview when the client avoids eye contact, responds in a very low voice, and is tearful, it would be most therapeutic for the nurse to state: 1. "You'll find that you get better faster if you try to help us to help you." 2. "Hold my hand; I know you are frightened. I will not allowed anyone to harm you." 3. "I'm your nurse. I'll take you to the day room as soon as I get some information." 4. "I know this is difficult, but as soon as we are finished, I'll take you to your room."
4. "I know this is difficult, but as soon as we are finished, I'll take you to your room."
Coping involves all of the conscious and unconscious behaviors used by individuals to deal with stress. Coping mechanisms are effective in maintaining emotional stability. Which coping mechanism is an ineffective mechanism? 1. Hitting others 2. Crying 3. Yelling 4. Kicking a chair
1. Hitting others
A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and rumors. The lithium level is 2.5 mEq/L. This level is indicative of which finding? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal
1. Toxic
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 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 client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the client's health care provider (HCP). 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay for "only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.
1. Contact the client's health care provider (HCP).
A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior is indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization
1. Denial
The physician prescribes olanzapine (Zyprexa) for a client with bipolar disorder, manic episode. The nurse should caution the client to: 1. Sit up slowly 2. Report double vision 3. Expect increased salivation 4. Take the medication on an empty stomach
1. Sit up slowly Rationale: Zyprexa can cause orthostatic hypotension.
A severely depressed client is to have electroconvulsive therapy (ECT). When discussing this therapy, the nurse should tell the client that: 1. Sleep will be induced and treatment will not cause pain 2. With new methods of administration, treatment is totally safe 3. It is better not to talk about it, but you can ask any question you like 4. There may be some permanent memory loss as a result of the treatment
1. Sleep will be induced and treatment will not cause pain
An older, depressed client frequently paces the halls, becoming physically tired from the activity. To help the client reduce this activity, the nurse should: 1. Supply the client with simple, monotonous tasks 2. Request a sedative order from the client's physician 3. Restrain the client in a chair, reducing the opportunity to pace 4. Place the client in a single room, thus limiting pacing to a smaller area
1. Supply the client with simple, monotonous tasks
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.
1. The adolescent gives away a DVD and a cherished autographed picture of a performer.
A hospitalized client is started on phenelzine (Nardil) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication (select all that apply)? 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies
3 & 5 Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include: yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, or figs.
A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"
3. "Do you feel afraid that people are trying to hurt you?"
A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been. few months since the incident. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fear about being raped again?"
3. "Tell me more about the incident that causes you to feel like the rape just occurred." Rationale: The correct option allow the client to express her ideas and feelings more fully and portrays a non hurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem-solving totally on the client.
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You will need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."
3. "You seem restless; tell me what is happening."
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the viriis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication. 2. Allowing increased "in-room" activities. 3. Increasing the level of suicide precautions. 4. Allowing the client off-unit privileges as needed.
3. Increasing the level of suicide precautions. Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such. dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself/herself. Suicide precautions are necessary to keep the client sage.
A client with depression is to receive fluoxetine (Prozac). A precaution that the nurse must remember when initiating treatment with this drug is that: 1. It must be given with milk and crackers to avoid hyperacidity and discomfort 2. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis 3. The blood level may not be sufficient to cause noticeable improvement for 2-4 weeks 4. Blood levels will need to be obtained weekly for 3 months to check for appropriate levels
3. The blood level may not be sufficient to cause noticeable improvement for 2-4 weeks
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."
3. You're feeling angry that your family continues to hope for you to be cured?"
A client states, "I get down on myself when I make a mistake." Using cognitive approach the nurse should: 1. Teach the client relaxation exercises to diminish stress 2. Provide the client with mastery experiences to boost self-esteem 3. Explore with the client past experiences that caused the client's distress 4. Help the client modify the belief that anything less than perfection is horrible
4. Help the client modify the belief that anything less than perfection is horrible
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse understands that which is the purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs
4. Helping the client to examine dysfunctional thoughts and beliefs
A client in the the hyperactive phase of a mood disorder, bipolar type, is receiving lithium carbonate. The nurse identifies that the client's lithium blood level is 1.8 mEq/L. It is most important for the nurse to: 1. Continue the usual dose of lithium and note any adverse reaction 2. Discontinue the drug until the lithium serum level drops to 0.5 mEq/L 3. Ask the physician to increase the dose of lithium because the blood lithium level is too low 4. Hold the drug and notify the physician immediately because the blood lithium level may be toxic
4. Hold the drug and notify the physician immediately because the blood lithium level may be toxic
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function. 2. Exploring the client's potential for self-harm. 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful. 4. Inquiring about and examining the client's feelings for any that may block adaptive coping.
4. Inquiring about and examining the client's feelings for any that may block adaptive coping.
A client is admitted to the mental health unit because of a progressively increasing depression over the past month. During the initial assessment, the nurse would expect the client to display: 1. Elated affect related to reaction formation 2. Loose associations related to thought disorder 3. Physical exhaustion resulting from decreased physical activity 4. Paucity of verbal expression related to slowed thought processes
4. Paucity of verbal expression related to slowed thought processes
While being treated, a client is introduced to short periods of exposure to the phobic object while in a relaxed state. What term is used to describe this form of behavior modification? 1. Milieu therapy 2. Aversion therapy 3. Self-control therapy 4. Systematic desensitization
4. Systemic desensitization
A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 1. Trusting 2. Working 3. Orientation 4. Termination
4. Termination Rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.
A psychotic client is receiving olanzapine (Zyprexa Zydis). When administering this drug, it is important that the nurse understand that this medication: 1. Can only be given IM 2. Requires a special tyramine-free diet 3. Should be taken on an empty stomach 4. Will dissolve instantly after placement in the client's mouth
4. Will dissolve instantly after placement in the client's mouth
The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and gracing as she watches television. The nurse determines that the client is experiencing which mediation complication? 1. Parkinsonism 2. Tardive dyskinesia 3. Hypertensive crisis 4. Neuroleptic malignant syndrome
2. Tardive dyskinesia
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior. 2. Asking the client to leave the group session. 3. Asking another nurse to escort the client out of the group session. 4. Telling the client that they will not be able to attend ay future group session.
1. Setting limits on the client's behavior.
Which are the characteristics of the termination stage of group development (select all that apply)? 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with each other. 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation.
1 & 6
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instruction regarding self-defense classes 4. Explaining the importance of leaving the violent situation
1. Information regarding shelters Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent persons. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.
Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals? 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Rational emotive therapy
1. Milieu therapy
Which side effect of tricyclic antidepressants is the most potentially dangerous? 1. Mydriasis 2. Dry mouth 3. Constipation 4. Urinary retention
1. Mydriasis Rationale: Mydriatic action can precipitate an acute attack of glaucoma, which could result in blindness.
The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 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 the client to report suicidal thoughts immediately
1. One-to-one suicide precautions
Incidents of child molestation that come out years later when the victim is an adult are best explained by the ego defense mechanism of: 1. Repression 2. Regression 3. Rationalization 4. Reaction formatoin
1. Repression
A nurse working on a unit in a psychiatric hospital is responsible for performing a variety of functions. Identify all those that a registered nurse is legally permitted to perform (select all that apply). 1. Psychotherapy 2. Health promotion 3. Case management 4. Prescribing medication 5. Identifying nursing diagnoses
2, 3, & 5
The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions (select all that apply)? 1. Libel 2. Battery 3. Assault 4. Slander 5. False Imprisonment
2, 3, 5
A hospice nurse is caring for the family of a client who has died 30 minutes ago. Which type of grief is the family experiencing in response to their loss? 1. Anticipatory grief 2. Acute grief 3. Complicated grief 4. Palliative grief
2. Acute grief
If clients do not abide by their diet restrictions while taking a monoamine oxidase inhibitor, it is likely that they will develop: 1. Generalized urticaria 2. An occipital headache 3. Sever muscle spasms 4. Sudden, severe hypotension
2. An occipital headache Rationale: An occipital headache is the beginning of a hypertensive crisis that results from too much tyramine.
The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 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?"
When the community health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response b the nurse illustrates a therapeutic communication response to this client? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. Sometimes, I have trouble sleeping, too."
3. "You're having difficulty sleeping?"
A depressed client has been started on a tricyclic antidepressant. The nurse teaches the client to expect to notice a significant change in the depression within: 1. 12-16 hours 2. 4-6 days 3. 1-4 weeks 4. 5-6 weeks
3. 1-4 weeks
What describes the primary focus of milieu therapy? 1. A form of behavior modification therapy 2. A cognitive approach to changing behavior 3. A living, learning, or working environment 4. A behavioral approach to changing behavior
3. A living, learning, or working environment
A male college student, who is smaller than average and unable to participate in sports, becomes the life of the party and a stylish dresser. This is an example of the defense mechanism of: 1. Introjection 2. Sublimation 3. Compensation 4. Reaction formation
3. Compensation
A client is receiving lithium carbonate. While this medication is being administered, it is important that the nurse: 1. Test the client's urine weekly 2. Restrict the client's sodium intake 3. Monitor the client's blood level regularly 4. Withhold the client's other medications for 2 weeks
3. Monitor the client's blood level regularly
Antidepressant drugs must be taken for ____ to ____ weeks before symptoms are relieved.
4 to 6 weeks
A nurse has been assigned to work with a depressed client on a one-to-one basis. The next morning the client refuses to get out of bed stating, "I'm too sick to be helped and I don't want to be bothered." The nurse's best response would be: 1. "You will not feel better unless you make the effort to get up and get dressed." 2. "I know you will feel better again if you only make the attempt to help yourself." 3. "Everyone feels this way in the beginning as they confront repressed feelings. I'll sit down with you." 4. "I know you don't feel like getting up, but you probably will feel better if you do. Let me help you get started."
4. "I know you don't feel like getting up, but you probably will feel better if you do. Let me help you get started."
The nurse sits with an older depressed client twice a day, although there is little verbal communication. One afternoon, the client asks, "Do you think they'll ever let me out of here?" The nurse's best reply would be: 1. "Why don't you ask your doctor?" 2. "Everyone says you're doing just fine." 3. "Why, do you think you are ready to leave?" 4. "You have the feeling that you might not leave?"
4. "You have the feeling that you might not leave?"
A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"
4. "You've been feeling like a failure for a while?"
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of physical activities that will provide exercise 3. No socializing activities, until the client asks to participate in milieu 4. A structured program of activities in which the client can participate
4. A structured program of activities in which the client can participate
When monoamine oxidase inhibitors (MAOIs) are prescribed, the patient should be cautioned against: A. prolonged exposure to the sun. B. active physical exercise. C. use of beta-blocking drugs for hypertension. D. ingesting wines and aged cheeses.
D. ingesting wines and aged cheeses.
A client with a diagnosis of major depression refuses to participate in unit activities because of being "just too tired." The nursing approach that best expresses an understanding of this client's needs would be: 1. Planning a rest period for the client during activity time 2. Explaining why the staff believes the activities are therapeutic 3. Helping the client express feelings of hostility toward the activities 4. Accepting the client's behavior calmly and, without excessive comment, setting firm limits
4. Accepting the client's behavior calmly and, without excessive comment, setting firm limits Rationale: The client is expressing hostility symbolically by not being cooperative. The client has a right to feel this way. If members of the staff criticize, it will only increase the client's feelings of guilt. Option 1 would allow the client to manipulate the environment. Option 2 will not change the client's mind about the activities. This response does not show an understanding of the client's needs. Option 3 will only increase feelings of guilt because the client is unaware of the hostility.
During a group session, it is learned that a female group member masked her depression and suicidal urges and indeed committed biocide several days ago. The group leaders should be prepared primarily to deal with the: 1. Guilt that group members feel because they could not prevent another's suicide 2. Lack of concern over the member's act of suicide expressed by some of the group 3. Fear, guilt, and anger of the colluders that they failed to anticipate and prevent the suicide 4. Anxiety and fear by some members of the group that their own suicidal urges may go unnoticed and unprotected
4. Anxiety and fear by some members of the group that their own suicidal urges may go unnoticed and unprotected Rationale: Ambivalence about life and death plus the introspection commonly found in clients with emotional problems would lead to increased anxiety and fear in the group members. Option 1 would likely be a secondary goal of the group leaders. Option 2 would not be a primary goal, but should be explored later to see what is behind apparent indifference. The feelings in Option 3 should be handled within the support and supervisory systems for the staff; the other group members are the primary concern.
A client has just been admitted to a long-term care facility following the loss of a spouse. A nurse assesses the client and determines that the client is in a state of bereavement. Which nursing interventions for bereavement should be included in the client's plan of care (select all that apply)? 1. Ensure safety and prevent violence 2. Promote interactions with others 3. Teach the client about the stages of grief 4. Facilitate spiritual support by including the client's spiritual or religious leader
1, 2, 3, & 4
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 they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a non-punitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
1, 3, 4, & 6
When assessing a client and attempting to distinguish between dementia and depression, the nurse should identify those adaptations that are unique to depression (select all that apply): 1. Apathetic 2. Labile affect 3. Changes in personality 4. Admits to memory losses 5. Disturbances in sleep patterns
1, 4, & 5
A common manageable side effect of neuroleptics is: 1. Ptosis 2. Jaundice 3. Melanocytosis 4. Unintentional tremors
4. Unintentional tremors
A nurse is evaluating the medication regimens of a group of clients to determine whether the therapeutic level has been achieved. For which medications should the nurse review the client's serum blood level? 1. Sertraline (Zoloft) 2. Lorazepam (Ativan) 3. Olanzapine (Zyprexa) 4. Valproic acid (Depakene)
4. Valproic acid (Depakene)
A client with schizophrenia has been taking the antipsychotic agent clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count
4. White blood cell count
A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration fo the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depression
2. At the same time each evening
The 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 for the nurse to obtain during this client visit regarding the side/adverse effects of the medication? 1. Cardiovascular symptoms 2. Gastrointestinal dysfunctions 3. Problems with mouth dryness 4. Problems with excessive sweating
2. Gastrointestinal dysfunctions
The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that this client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Sign of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission
2. Normal reactions to a devastating event
When asked why she does not take the prescribed antihypertensive medication, a client states she does not take medication to lower her blood pressure because she cannot swallow pills and they probably won't work anyway because her body was just meant to have higher blood pressure than other people. This is an example of the use of which defense mechanism? 1. Sublimation 2. Rationalization 3. Reaction formation 4. Intellectualization
2. Rationalization
A hospitalized client has begun taking bupropion (Wellbutrin) as an antidepressant agent. The nurse understands that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright
2. Seizure activity
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure the client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a stage member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed
3. Assigning a stage member to the client who will remain with the client at all times
Sublimation is a defense mechanism that helps the individual: 1. Act out in reverse something already done or though 2. Return to an earlier, less mature, stage of development 3. Channel unacceptable sexual desires into socially approved behavior 4. Exclude from consciousness things that are psychologically disturbing
3. Channel unacceptable sexual desires into socially approved behavior Rationale: The individual using sublimation attempts to fulfill desires by selecting a socially acceptable activity rather than one which is socially unacceptable.
A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for this past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinical neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3-4 hours during the day.
3. Client arrives at the clinical neat and appropriate in appearance.
A manic client begins to make sexual advances towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client comes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of the other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.
3. Escort the client to their room, with the assistance of the other staff.
To prevent relapse in a client with a psychiatric illness, the most important information the nurse should teach the client is to: 1. Develop a close support system 2. Create a stress free environment 3. Reframe from activities that cause anxiety 4. Follow the prescribed medication regimen
4. Follow the prescribed medication regimen
A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight. 2. Continue driving as usual. 3. Avoid foods rich in potassium. 4. Get up slowly when changing positions.
4. Get up slowly when changing positions.
The two main types of stress are ___________________ stress and ___________________ stress.
developmental & situational
