Mental Health Practice A

A nurse is caring for a group of clients. Which of the following findings should the nurse report? a) a client who is taking clozapine and has WBC of 7,500/mm^3 b) a client who is taking lamotrigine and has developed a rash c) a client who is taking valproate and has a platelet count of 150,000/mm^3 d) a client who is taking lithium and has a lithium level of 1.2mEq/L

A client who is taking lamotrigine and has developed a rash. Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? a) call the family member to the side to inquire if they have questions or concerns about the treatment plan b) advise the family member that this treatment plan has been developed specifically for the client to follow c) ask the family member if they have any thoughts or questions about the treatment plan d) document that the family member does not support the medication treatment plan

Ask the family member if they have any thoughts or questions about the treatment plan. this action involves the family member and allows them a venue to communicate about the clients medication treatment plan

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? a) promote the use of music to compete with the clients auditory hallucinations b) inform the client that the auditory hallucinations are not real c) avoid asking that the client if they are experiencing auditory hallucinations d) instruct the client on the use of voice recognition regarding the auditory hallucinations

Promote the use of music to compete with the client's auditory hallucinations. competing reality based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the clients stress level informing the client that auditory hallucinations are not real will increase the clients anxiety level. The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that they do not hear anything to reinforce reality the nurse should ask the client if they are hearing voices to evaluate whether these are command hallucinations which can place harm on themselves or others the nurse should assist the client to develop the skill of voice dismissal when auditory hallucinations occur. this involves commanding the voices to stop, which gives the client a sense of control

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? a) the client is exhibiting echolalia b) the client reports command hallucinations c) the client reports loss of motivation d) the client is exhibiting blunted affect

The client reports command hallucinations command hallucinations can induce a potential psychiatric emergency for a client who has schizophrenia, command hallucinations can direct the client to harm themselves or others

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?

Remove unnecessary equipment from the child's surroundings.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Report the occurrence to the charge nurse

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

Substance abuse disorder

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?

Talk with the client about activities they enjoyed with their partner.

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Set realistic limits on the client's behavior

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? a) shuffling gait b) hypotension c) decreased WBC count d) blurred vision

Shuffling gait benztropine is used to treat parkinsonism manifestation such as shuffling gait

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? a) I put in extra hours at work so I wont think about drinking b) I know that wine is good for my heart, so that is why I drink some each evening c) I make up for my drinking by taking my partner on nice vacations d) I am able to go to work every day, so I don't have a problem

"I am able to go to work every day, so I don't have a problem." by insisting that their drinking is not a problem because they can go to work everyday, the client is using denial allowing them to ignore the existence of their substance disorder I client who consciously avoids thinking about uncomfortable feelings or thoughts is using suppression by relating their drinking every evening to their heart health, the client is using the defense mechanism of rationalization a client who attempts to make up for an undesireable act by doing something positive is using undoing

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning."

A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? a) I should eat a regular diet with normal amounts of salt and fluids b) I should discontinue the lithium when I begin to feel better c) I need to be careful to avoid becoming addicted to the lithium d) I can skip a dose of medication if my stomach is upset

"I should eat a regular diet with normal amounts of salt and fluids." normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium, if sodium levels are low the body compensates by decreasing lithium excretion, which can lead to toxicity

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? a) if you do my homework for me, I wont bother you for the rest of the day b) mom is always upset c) its not the childrens fault, its mine d) its your fault that we're having problems as a family

"If you do my homework for me, I won't bother you for the rest of the day." this is an example of manipulative behavior, it is manipulation when someone uses a behavior to get what they desire vs. directly asking

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?

"In the event a client threatens to harm others, medication can be administered without consent."

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? a) im relieved now that my financial affairs are in order b) it is easier to talk about my feelings now c) suddenly I have enough energy to do anything I want d) thank you for always taking such good care of me

"It is easier to talk about my feelings now." when a client express their feelings, this indicates a positive treatment outcome when a client with depression verbalizes getting their affairs in order they are at an increased risk for suicide clients with depression who have more energy that are at an increased risk for suicide clients who have depression often show an appreciation for loved ones when they are contemplating suicide

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

"It is not uncommon to feel angry toward yourself or others."

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

"You might experience difficulties with sexual functioning while taking this medication."

A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? a) feelings of hopelessness b) pressured speech c) grandiosity d) anhedonia e) flat facial expression

-Feelings of hopelessness -Anhedonia -Flat facial expressions anhedonia- inability to experience pleasure pressured speech and grandiosity is associated with mania, not depression

A nurse is caring for a group of clients. For which of the following situations should the nurse complete the incident report? a) a client refuses ECT therapy after signing the consent form b) a client who was voluntarily admitted left the unit against medical advice c) a client was administered one-half of the prescribed dose of medication d) a client was placed in restraints after attempts to de-escalate aggressive behavior

A client was administered one-half of the prescribed dose of medication. an incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity?

A client who has a sodium level of 128 mEq/L

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?

A client who has borderline personality disorder threatened to harm their roommate

A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? a) feelings of remorse b) extended periods of depression c) deficits in intellectual functioning d) aggression toward animals

Aggression towards animals the nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder LACK of remorse is an expected characteristic of conduct disorder extended periods of depression is a characteristic of bipolar disorder deficits in intellectual functioning is not a characteristic of conduct disorder

A client who has a diagnosis of depression is attending a group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? a) allow the client time to formulate an answer b) prompt the client to give a response c) move on to the next client d) offer the client a suggestion for a goal

Allow the client time to formulate an answer

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?

Anhedonia

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?

Arrange one-to-one observation of the client.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

Ask the client what the voices are saying

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. the client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

Assess the client for evidence of a perceptual disturbance

A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include?

Attending a relapse prevention group several times each week.

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?

Attention to body language

A nurse is providing teaching to a client who is to begin undergoing light therpay at home. Which of the following information should the nurse include in the teaching? a) ensure a family member can be present during treatment b) increase fluid intake for 24hr before the treatment starts c) change position slowly when the treatment is complete d) avoid looking directly at the light during treatment

Avoid looking directly at the light during treatment.

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a) obtain the weight of a client who has bipolar disorder and is experiencing mania b) assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past two days c) monitor the cardio status of a client who is experiencing serotonin syndrome d) change the dressings of a client who has borderline personality disorder and superficial self inflicted wounds

Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. a client who has BPD is at risk for self mutilation such as cutting, self inflicted wounds, scratching, or picking. It is within the LPN scope of practice to change the dressing the AP is able to take daily weight Monitoring cardio status and assessments are within the scope of the RN

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? a) clang association b) word salad c) neologism d) echolalia

Clang association a nurse should document that the clients speech uses clang associations which often rhyme or contain a string of words that can have similar sound word salad words are completely meaningless and disorganized neologism consists of words that are made up by the client echolalia the client repeats words of another person

A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mmHg and a temperature of 39.9 degrees Celsius. Which of the following actions should the nurse take first?

Determine the client's prescribed medication regimen.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?

Diazepam 5 mg IV bolus greatest risk to the client who is experiencing alcohol withdrawal is seizures, and elevated heart rate, and elevated BP. IV diazepam acts rapidly to prevent seizures, stabilize vitals, and decrease the intensity of withdrawal manifestations.

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?

Do not administer the lorazepam

A nurse assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Emotional lability

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? a) have the client participate in a morning aerobics group b) encourage frequent rest periods throughout the day c) provide a distraction such as television at night d) offer the client hot chocolate at bedtime

Encourage frequent rest periods throughout the day. a client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. encouragement periods of rest throughout the day can limit the risk of exhaustion

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?

Frequently misplaces objects

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take? a) gather supplies for endotracheal intubation b) administer a beta blocker IV c) position the client in a low fowlers position d) place a cooling blanket over the client

Gather supplies for endotracheal intubation. remember rule of ABC, also an expected finding of an unresponsive client with alcohol toxicity is respiratory depression

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? a) raise the pitch of the voice when speaking to the client b) begin the interview by explaining the plan of care c) interview the client in a private setting d) ask the client to complete a detailed questionnaire

Interview the client in a private setting you should interview clients in a private setting when asking questions regarding client health

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Hand tremors

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? a) polyphagia b) hypertension c) decreased temperature d) depressed mood

Hypertension cocaine is a stimulant that increases blood pressure, it also increases HR, body temp, energy levels, and metabolism

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?

Inappropriate dress

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? a) advise the client to take frequent sips of water b) instruct the client to avoid driving during initial therapy c) consult a dietitian for a calorie-controlled diet plan d) recommend that the client exercise regularly

Instruct the client to avoid driving during initial therapy greatest risk to this client is injury resulting from drowsiness or dizziness therefore the nurses priority intervention is to instruct the client to avoid activities that require mental alertness during initial therapy

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?

Orthostatic hypotension

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following? a) schedule the client for group therapy sessions b) maintain consistent rules c) provide frequent high calorie snacks d) avoid the use of valve judgements

Provide frequent high-calorie snacks the priority action the nurse should take when using the maslows hierarchy of needs is to meet the clients need for adequate nutrition. therefore providing high calorie snacks is the priority action for the nurse to take

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? a) controls anger outbursts to avoid being placed in seclusion b) no longer exhibits a fear of social or public situations c) refrains from manipulating others to earn dining room privileges

Refrains from manipulating others to earn dining room privileges. the goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. refraining from manipulative behavior is a desired response changing behavior to avoid punishment is not an optimal goal of operant conditioning imitating behavior is modeling and does not demonstrate the desired outcome

A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? a) respite care b) partial hospitalization c) adult day care program d) geropsychiatric unit

Respite care respite care programs allow the client to stay in a nursing facility for a set number of day allowing the caregivers to go on vacation or have some time to themselves

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? a) St. Johns wort b) saw palmetto c) echinacea d) ginko

St. John's Wort St. Johns wort is an herbal supplement that decreases the reuptake of serotonin, taking this medication along with another SSRI can increase risk of serotonin syndrome saw palmetto is used to treat BPH and does not interact Echinacea is used for immune function ginko is used to relieve pain from PAD

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? a) the client is interested in what the nurse is saying b) the client is attempting to manipulate the nurse c) the client is physically attracted to the nurse d) the client needs to feel accepted by the nurse

The client is interested in what the nurse is saying. the clients posture and eye contact demonstrates an interest in the interview and what the nurse is saying

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make everyday decisions.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash.

A nurse is reviewing the electronic medical record of a client who has scizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

The client reports an inability to breathe easily.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

The client will refrain from self-mutilation.

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%

A nurse is caring for a client who is undergoing electroconvulsive therapy and will receive succinycholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? a) succinylcholine will enhance the therapeutic effects of this treatment b) succinylcholine is given to reduce muscle movements during therapy c) succinylcholine will decrease the anxiety level that you might experience with this treatment d) succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure

"Succinylcholine is given to reduce muscle movements during therapy." succinylcholine is a muscle paralyzing agent that will decrease muscle movement during the procedure so the client is less likely to be injured

A nurse in a provider;s office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

Dark urine