Mental Health - Practice Test
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make? "I can arrange for a female assistive personnel to do your personal hygiene care." "The nurse assigned to care for you is very capable and cares for other women in this situation." "Your doctor is a man, so it seems like this should not be a problem." "I can review the assignments and arrange for a female nurse to care for you."
"I can review the assignments and arrange for a female nurse to care for you."
A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? "Of course people care. Your family comes to visit every day." "Why do you feel that way?" "Tell me who you think doesn't care about you." "I care about you, and I am concerned that you feel so sad."
"I care about you, and I am concerned that you feel so sad." This is an open-ended therapeutic statement that focuses on the client's feelings, shows empathy, and allows for further exploration of the client's belief that life is not worth living in order to keep the client safe from suicidal thoughts.
A nurse is caring for a client who has borderline personality disorder. As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client? "We do this every day. Why are you so angry with me this morning?" "I don't like it when you address me with that tone of voice." "I know you can, but are you going to read it or not?" "Fine. Here is the schedule, and I will expect you to be on time to your therapies."
"I don't like it when you address me with that tone of voice." BPD is described as an emotionally unstable personality. Clients who have BPD might show a wide range of impulsive behaviors in all aspects of their lives, including self-destructive behaviors. The client in this situation has overstepped a limit by addressing the nurse in a less-than-respectful tone of voice. This therapeutic response calls to the client's attention the inappropriate behavior and sets appropriate limits for further communication. This is the best approach to continue communication with this client.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? "I'm sure that the bugs you see will not harm you." "Tell me more about the bugs that you see in your room." "I don't see any bugs, but you seem very frightened." "I do not see anything. This is part of the withdrawal process."
"I don't see any bugs, but you seem very frightened." This client is experiencing a tactile hallucination, which is common during alcohol withdrawal. This response by the nurse presents reality and shows empathy by acknowledging the client's feelings.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification? "I have heard that abusers try to keep their partner isolated from others." "I know that abusers lack social supports and social skills." "I know that men who are abusers gain power through intimidation." "I have heard that abusers think of themselves as important and have high self esteem."
"I have heard that abusers think of themselves as important and have high self esteem." Victimizers typically have low self esteem and diminished feelings of self-worth. They may show a different type of personality to the community than the one shown to the partner.
A nurse is teaching a client who has a new prescription of paroxetine. Which of the following statements by the client indicates an understanding of the teaching? "I may experience an increased desire to have sex." "My blood pressure may increase." "I may notice excess saliva." "I may not feel like eating as much."
"I may not feel like eating as much." Anorexia and a decreased appetite are adverse effects of paroxetine.
A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for bupropion. Which of the following statements by the client indicates understanding of the teaching? "I may develop a slow heartbeat while taking bupropion" "I can drink one glass of wine with dinner each day while taking bupropion" "I may not notice a lifting of my mood for at least 2 weeks" "I should watch for increased salivation and drooling while taking bupropion"
"I may not notice a lifting of my mood for at least 2 weeks" Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI). As with other antidepressants, it can take 2 to 4 weeks for therapeutic effects to occur when taking bupropion.
A nurse is proving teaching for a client who has a new prescription for clozapine. Which of the following statements indicates the client understands the teachings? "This medication will help prevent seizures." "This medication will be administered by intramuscular injection every 2 weeks." "I should expect to develop ringing in my ears while taking this medication." "I will rise slowly from a lying position to prevent fainting while taking this medication."
"I will rise slowly from a lying position to prevent fainting while taking this medication." Clozapine can cause orthostatic hypotension, especially during the first few weeks of therapy. The client should be taught to rise slowly from a lying or sitting position.
A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teachings? "I will take my dose of orlistat every morning an hour before breakfast." "I will eat a no-fat diet to prevent side effects from the medication." "I will stop taking orlistat and call my doctor if my urine gets darker in color." "I will feel less hungry during meals while I am taking orlistat."
"I will stop taking orlistat and call my doctor if my urine gets darker in color." Orlistat can cause severe liver damage; therefore, the client should be taught manifestations of liver damage, including dark-colored urine, light-colored stools, jaundice, anorexia, vomiting, and fatigue.
A nurse is teaching a newly licensed nurse about reporting suspected child abuse? Which of the following statements indicates an understanding by the newly licensed nurse? "Evidence must exist prior to reporting." "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." "I don't want to defame someone if the report is false." "If suspicion of abuse exists then reporting is mandatory."
"If suspicion of abuse exists then reporting is mandatory."
A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation? "This morning, this morning, this morning..." "It was good. The Queen of England visited me there." "I just don't remember what I did this morning." "Snip, snap. Take a nap."
"It was good. The Queen of England visited me there." Confabulation occurs when a client who has dementia unconsciously makes up or fills in made-up information when she has memory loss. Confabulation is sometimes mistaken for lying. However, lying is done consciously and confabulation is done unconsciously to maintain self-esteem.
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching? "The legal requirement for client confidentiality ceases if the client is deceased." "Staff members are required to divulge information to attorneys if they call for information." "Health care workers are not required to answer a court's requests for information about a client's disclosure." "Providers are required to warn individuals if the client threatens harm."
"Providers are required to warn individuals if the client threatens harm." Health care professionals have a duty to warn and protect third party individuals who may be in danger due to the client's threats of harm.
A nurse is admitting a client who has multiple injuries following a MVA. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make? "Do not worry about that. Your wife will be fine." "I think you should calm down a little before you see your partner." "Why do you think the crash is your fault?" "Tell me more about your feelings about what happened to your partner."
"Tell me more about your feelings about what happened to your partner."
A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statement should the nurse make? "I understand your grief. I lost a baby also." "You may hold your baby as long as you want." "I have called for the chaplain to come and stay with you." "This is for the best. Your baby was very ill."
"You may hold your baby as long as you want."
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make? "You are mistaken. Nobody is lying about you or trying to poison you." "You seem to be having very frightening thoughts." "Why do you think you are being lied about and poisoned?" "Who is lying about you and trying to poison you?"
"You seem to be having very frightening thoughts." When responding to a client who is delusional, the nurse should avoid making statements that directly confront or affirm the client's delusional beliefs. Instead of responding literally to the client's words, the nurse should respond to the feelings that the client is attempting to communicate. By doing this, the nurse is shifting the focus from the delusional beliefs, which are not real, to the client's fear, which is real.
A nurse is proving medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching? "You should change positions slowly while taking this medication." "This medication is prescribed to help overcome alcohol addiction." "You should omit foods containing oxalates while taking phenalzine." "You should avoid drinking liquids after your evening meal."
"You should change positions slowly while taking this medication." Clients should change positions slowly while taking an MAOI due to the risk of orthostatic hypotension. Lightheadedness and fainting are common when taking phenelzine.
A nurse is caring for a client who has MDD and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? a. "You have a great deal to live for" b. "It's not unusual for depressed people to feel that way" c. "Why do you feel you are worthless" d. "You've been feeling that your life had no meaning"
"You've been feeling that your life has no meaning" This open-ended statement uses the communication tool of empathy and addresses the client's feeling of worthlessness. This therapeutic response communicates to the client that the nurse was listening, and it will encourage the client to talk further about personal feelings.
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy? A client who has been taking amitriptyline for 3 months for depression A client exhibiting psychotic behavior A client admitted 12 hr ago for acute mania A client who is experiencing alcohol intoxication
A client who has been taking amitriptyline for 3 months for depression Psychotherapy groups provide clients with the opportunity to enhance their personal relationships, increase self-awareness, and try new behaviors in a safe social setting. Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be experiencing improvement in depressive manifestations and be ready to interact in a group setting.
A nurse is caring for several clients who have mental health disorders at a ALF. Which of the following clients should the nurse determine needs to be seen by a provider immediately? A client who is taking olanzapine and experiences dizziness when first standing up A client who is taking chlorpromazine and reports vomiting twice A client who is taking thioridazine and has daytime drowsiness A client who is taking clozapine, and has flu-like manifestations
A client who is taking clozapine, and has flu-like manifestations Clozapine is used to treat schizophrenia and can cause life-threatening agranulocytosis. Presence of flu-like manifestations indicates that this is the client at greatest risk; therefore, the nurse should contact this client's provider immediately.
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client? A semi-private room across from the day room. A private room in a quiet location on the unit. A private room across from the exercise room. A semi-private room across from the snack area.
A private room in a quiet location on the unit. A private room decreases stimuli for the client and does not subject another client to his overactive behavior.
A nurse is assessing for the presence of EPS in a client who is taking chlorpromazine. Which of the following finding should the nurse recognize as EPS? (SATA) a. Muscle spasms of the neck b. Fidgeting behavior c. Blurred vision d. Tremors of the hands e. Sexual dysfunction
ABD Muscle spasms of the neck is correct Fidgeting behavior is correct. Tremors of the hands is correct.
A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (SATA) a. Paroxetine b. Lithium c. Donepezil d. Valproate e. Carbamazepine
ABDE
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (SATA) a. Avoid wearing necklaces during client care. b. Know the layout of the facility. c. Stand directly in front of the client when talking. d. Bring security with you for all client interactions. e. Provide immediate verbal feedback for escalating behavior.
ABE Avoid wearing necklaces during client care is correct. Know the layout of the facility is correct. Provide immediate verbal feedback for escalating behavior is correct.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? Xenophobia Acrophobia Mysophobia Agoraphobia
Agoraphobia
A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take? Act to the client as if the hallucination is real. Instruct the client to argue with the voices that are a part of the hallucination. Ask the client direct questions about the hallucination. Tell the client that the hallucination is not a part of reality.
Ask the client direct questions about the hallucination. Asking the client direct questions about the hallucination provides important data to identify the client's risk level and current mental status.
A nurse is caring for a client who has anorexia nervosa and overexercising to avoid gaining weight. Which of the following nursing actions should the nurse take? Praise the client for looking at herself in a mirror. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. Reprimand the client about the potential damage that has occurred due to overexercising her body. Restrict the client from being weighed.
Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. To promote effectiveness of treatment, the nurse should implement actions which establish trust and partnership with the client. This action should help the client view the nurse as a partner in treatment.
A nurse in an ED is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take? Discuss self-defense techniques with the client. Inform the client photographs of injuries are required for a police report. Ask the client to describe the situation. Give the client a bed bath prior to physical examination.
Ask the client to describe the situation. During the acute phase following assault, the nurse should encourage the client to provide information which may be helpful with treatment and to reduce the client's anxiety.
A nurse asks a client ho is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority? Lock the doors to the unit and secure windows so they cannot be opened. Provide the client with plastic eating utensils for meals. Remove any objects from the client's environment that could be used for self-harm. Assign a staff member to stay with the client at all times.
Assign a staff member to stay with the client at all times. The greatest risk to this client is self-injury during unsupervised time; therefore, the nurse should identify the priority action is to assign a staff member to stay with the client at all times. The staff member can monitor all of the client's behaviors and actions and prevent the client from harming herself.
A nurse is caring for a child who has autism pecturm disorder. Which of the following findings should the nurse expect? (SATA) a. Short attention span b. Delayed language development c. Spinning a toy repetitively d. Ritualistic behavior e. Consistent limit testing
BCD Delayed language development is correct Spins a toy repetitively is correct. Ritualistic behavior is correct. A delay in speech and language development is an expected finding of autism. Interest in repetitive activities is an expected finding of autism. A need for routine and the presence of ritualistic behavior are expected findings of autism.
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (SATA) a. Severe hypotension b. Visual hallucinations c. Hyperglycemia d. Insomnia e. Tremors
BDE
A nurse in the ED is caring for a client who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident? Psychologist Close friend Social worker Chaplain
Close friend Sexual assault survivors who confide in a family member or friend immediately after the incident are more likely to develop fewer somatic manifestations of stress.
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? Visual hallucination Gustatory hallucination Command hallucination Tactile hallucination
Command hallucination
A nurse is planning care for a client newly admitted with MDD. Which of the following actions should the nurse plan to take? Ask the client to create her own schedule of daily activities. Teach the client to use passive communication when interacting with others. Determine the client's need for assistance with grooming. Limit the client's involvement in unit activities.
Determine the client's need for assistance with grooming. The nurse should promote problem-solving by helping the client identify situations which can or cannot be controlled. This can help the client deal with unresolved issues.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority? Determining if the client has psychotic thinking Asking the client to identify the cause of the crisis Identifying the client's coping skills Identifying the client's support systems
Determining if the client has psychotic thinking Clients experiencing a situational crisis are at greatest risk for injury to themselves or others; therefore, determining if psychotic thinking is present is the highest priority.
A nurse in an ED is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect? Nystagmus Dilated pupils Hypersomnia Depression
Dilated pupils Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system.
A nurse in an ED is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first? Ask the client for permission to take photographs. Document the client's verbatim statements. Provide community sexual assault support contacts. Determine any physical signs of injury.
Document the client's verbatim statements. The first action the nurse should take is to document the client's actual statements.
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? Dysrhythmias Cataracts Pancreatitis Bleeding
Dysrhythmias Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol. There is a risk for cardiac arrest due to torsades de pointes.
A nurse is caring for a client what as autism spectrum disorder. Which of the following findings should the nurse expect? Expressive affect Associative looseness Echolalia Ambivalence
Echolalia
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? Experiencing diarrhea Exercising moderately Increasing sodium intake Drinking green tea
Experiencing diarrhea Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the level of lithium in the blood becomes too high. A low sodium level, or factors which result in a low sodium level, (such as dehydration, diarrhea, sweating, excess exercise in hot weather, diuretic use, a low sodium diet) increases the lithium level because the kidney processes sodium and lithium in the same way. If sodium levels fall, the body conserves lithium, causing lithium levels to rise.
A community health nurse is proving teaching to the family of client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? Decreased auditory and visual acuity Decreased display of emotions Personality traits that are opposite of original traits Forgetfulness gradually progressing to disorientation
Forgetfulness gradually progressing to disorientation Dementia usually appears first as forgetfulness. Other manifestations may be apparent only upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.
A nurse is planning care of a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? Monitor the client closely to prevent self-mutilation. Set limits to prevent exploitation of other clients. Discourage flamboyant or seductive behaviors. Give positive feedback when client is assertive with staff or clients.
Give positive feedback when client is assertive with staff or clients. The client who has dependent personality disorder has great difficulty demonstrating assertive behavior and commonly relies on others to make decisions. The nurse should encourage the client to be more assertive and independent.
A nurse is caring a client following a recent suicide attempt. Which of the following actions should the nurse take? Place metal utensils on the client's meal tray. Assign the client to a private room. Inspect the client's personal belongings. Tuck bedcovers over client's hands and arms.
Inspect the client's personal belongings. Inspecting the client and his personal belongings is an appropriate intervention to ensure that the client does not have access to potentially harmful objects.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving? Leaves the child's room exactly as it was before the loss Volunteers at a local children's hospital Talks about the child in the past tense Visits the child's grave every week after worship services
Leaves the child's room exactly as it was before the loss Grieving becomes dysfunctional when the client is unable to resume regular activities of daily living or experience emotions other than sadness or depression. An example of dysfunctional grieving is making the loved one's room a shrine for more than a year.
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurses include in plan of care? Provide a cognitively stimulating environment. Rotate staff to prevent caregiver role strain. Limit the client's choices for daily activities. Use confrontation to manage negative behavior.
Limit the client's choices for daily activities. Limiting the client's choices is appropriate for a client who has dementia as this intervention decreases the client's level of anxiety.
A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take? Maintain a nonjudgmental attitude. Avoid displaying an emotional response. Offer sympathetic support. Verbalize disapproval of the client's substance abuse.
Maintain a nonjudgmental attitude. When developing a therapeutic relationship with any client, including a client who has an addictive disorder, it is important that the nurse remain nonjudgmental, showing positive regard for the client as a person.
A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take? Make a contract with the client not to drive over the speed limit. Call the local police and alert them to the client's car license plate number and the make and model of her car. Ask the client to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. Inform the client that she cannot drink and drive.
Make a contract with the client not to drive over the speed limit. A behavior contract is appropriate to identify the expected behavior and consequences. The client, by signing the contract, assumes responsibility for her behavior.
A nurse is caring for a client who is withdrawing from opioids. Which of the following medications should the nurse prepare to administer? Methadone Disulfiram Risperidone Lithium carbonate
Methadone Methadone is a synthetic opiate that blocks the craving for and the effects of narcotics. It is widely used to assist with detoxification and maintenance of those who have a dependency to opioids. Methadone reduces withdrawal symptoms, but it does not cause a high. The medication must be taken every day. The client requires close monitoring because methadone is highly addictive. Methadone is approved for the treatment of women who are pregnant and addicted to opioids.
A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occuring? Tardive dyskinesia Neuroleptic malignant syndrome Acute dystonia Pseudoparkinsonism
Neuroleptic malignant syndrome The client's findings indicate possible neuroleptic malignant syndrome which is a potentially life-threatening adverse effect of antipsychotic medications. The nurse should promptly recognize and report findings of neuroleptic malignant syndrome since prompt treatment is necessary.
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5 C (103.4 F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complication should the nurse suspect? a. Agranulocytosis b. NMS c. Akathisia d. Tardive dyskinesia
Neuroleptic malignant syndrome Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of antipsychotic medications that requires emergency medical intervention. Manifestations of NMS are sudden and include changes in level of consciousness, seizures, and stupor.
A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of following clients should the nurse suggest offering the therapy to? Post-traumatic Stress Disorder Schizophrenia Pedophilia Paranoid personality disorder
Post-traumatic Stress Disorder Guided imagery is a recommended treatment to relieve the anxiety associated with post-traumatic stress disorder. It is a complementary alternative therapy also used to treat sleep disorders, anxiety, and pain.
A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following id the priority intervention for the nurse to make? Promote appropriate behavior during group therapy sessions. Encourage client input in the treatment plan. Communicate with the client using concrete language. Demonstrate assertive behavior.
Promote appropriate behavior during group therapy sessions. Managing the client's behavior within the group is the priority intervention for the client who has histrionic personality disorder because these clients display extreme attention-seeking behaviors and are often impulsive, which can be extremely disruptive in a group setting with other members.
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority? Protecting the client from injury Determining the cause of the client's anxiety Ensuring that the client feels safe Identifying the client's coping skills
Protecting the client from injury The greatest risk to this client is harm to himself through suicide or other injury when not in control of his actions, or to others while experiencing panic-level anxiety. Therefore, the priority is to protect the client from injury. The presence of panic-level anxiety is a risk factor for suicide.
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? Post a written schedule of daily activities. Use an overhead loudspeaker to announce events. Provide a consistent daily routine. Allow the client to choose free-time activities.
Provide a consistent daily routine.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which os the following interventions should the nurse identify as the priority? Helping the client identify positive personality traits Providing for adequate hydration and rest Confronting the use of denial and other defense mechanisms Educating the client about the consequences of alcohol misuse
Providing for adequate hydration and rest Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatment. Rest is important for two reasons: alcohol use disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with increased restlessness and agitation. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.
A nurse on an inpatient mental health unit is caring for a client who has MDD and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status? Enroll the client in a nutritional class on the unit. Weigh the client at the same time every morning. Ask provider to arrange a consultation with the facility chaplain. Sit with the client during meals and snacks.
Sit with the client during meals and snacks. A change in appetite is a major symptom of depression. Being present during meals and snacks to support and encourage the client is an appropriate nursing intervention that might help the client at this time.
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing? Situational Maturational Adventitious Developmental
Situational This client situation is an example of a situational crisis which refers to loss or change that is often unexpected. A maturational crisis refers to a crisis involving new stages of growth and development. An adventitious crisis refers to a crisis such as a natural disaster or act of violence. A developmental crisis refers to a crisis involving new stages of growth and development.
A nurse is caring for a client who had MDD. Which of the following findings should the nurse expect? A dismissal of past failures Psychomotor agitation An increase in energy Sleep disturbances
Sleep disturbances Sleep disturbances are common in clients with depression.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? Acute pancreatitis Slowed breathing Nasal septum perforation Permanent short-term memory loss
Slowed breathing Slowed or arrested breathing is just one of the many physical complications related to heroin use. Others include drowsiness, impaired coordination, nausea, and sedation.
A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an expected finding? Death of client's father two months ago Experiences frequent facial tics Suspended from school several times in the past year Adheres strictly to routines
Suspended from school several times in the past year Conduct disorder is an impulse-control disorder which includes a long-term pattern of violating the rights of others and performing violent or hostile acts.
A nurse on a long-term care unit is creating plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? Rotate assignment of daily caregivers. Provide an activity schedule that changes from day to day. Limit time for the client to perform activities. Talk the client through tasks one step at a time.
Talk the client through tasks one step at a time. The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level.
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take? Talk to the client and identify the specific limits that are required of the client's behavior. Discuss the problem in a community meeting with the other clients on the unit present. Escort the client to her room each time the nurse observes the client socializing with other clients. Tell the other clients to ignore the client's lies.
Talk to the client and identify the specific limits that are required of the client's behavior. Discussing the problem behaviors with the client and informing her of which behaviors cannot be done on the unit is therapeutic communication.
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after 72-hr hold is over for which of the following conditions? The client is a danger to herself or others. The client is unwilling to accept that treatment is needed. The client states that she does not like the neighbor. The client states that she plans to move out of the state immediately.
The client is a danger to herself or others. The criteria for involuntary admission includes that the client has a mental disorder that will likely result in serious bodily harm to self or another person, unless the client remains in a psychiatric facility.
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania? The client's spouse reports that client has recently gained weight. The client is dressed in all black. The client responds to questions with disorganized speech. The client reports that voices are telling him to write a novel.
The client responds to questions with disorganized speech.
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? The client runs 4 miles outdoors every afternoon. The client drinks 2 liters of liquids daily. The client eats 2 to 3 gm of sodium-containing foods daily. The client eats foods high in tyramine.
The client runs 4 miles outdoors every afternoon. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb, and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? he client is 48 years old. The client's husband died seven months ago. The client has lost 30 lb. The client is having difficulty sleeping.
The client's husband died seven months ago. One of the defining factors of maladaptive grieving is grief that lasts 6 months or longer after the loss.
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority? The client will acknowledge alcohol dependence and need for treatment. The client will rebuild damaged interpersonal relationships. The client will implement alternative strategies for managing anxiety. The client's withdrawal from alcohol will be managed without complications.
The client's withdrawal from alcohol will be managed without complications. The greatest risk to the client is injury and adverse effects of withdrawal; therefore, this goal is the highest priority.
The nurse is making a home visit with a client diagnosed with Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? The partner has placed locks at the top of the doors leading to the outside. The partner has hired a house cleaner. The partner has lost 20 lb in the past 2 months. The partner redirects the client when the client is frustrated.
The partner has lost 20 lb in the past 2 months. A large weight loss by the caregiver is an indication of caregiver role strain.
a nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations? Attention-seeking conduct Mild difficulty problem solving Mild fidgeting Threatening behavior
Threatening behavior The client experiencing severe anxiety can have feelings of confusion and impending doom. The client may feel the need to be aggressive and defensive, speaking with loud, rapid speech and possibly making threats and demands of others.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? Rapid speech Chills Distorted perceptual field Urinary frequency
Urinary frequency The nurse should expect the client who has moderate anxiety disorder to exhibit urinary frequency, as well as headache, backache, and insomnia.
A nurse is teaching about ECT with a newly licensed nurse. The nurse should identify that the newly licensed nurse understands the teaching when she states that ECT treats which of the following disorders? Narcotic addiction Vegetative depression Personality disorder Eating disorder
Vegetative depression