Mental Health

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. WHich of the following response should the nurse make? A "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." B "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." C "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen." D "The most common side effects are directly related to the use of anesthesia."

A

Which of the following findings should the nurse identify as a negative symptom of a client who has schizophrenia? A Affective flattening B Bizarre behavior C Illogicality D Somatic delusions

A

A nurse is providing teaching about confidentiality with a new RN. Which of the following statments by the newly RN indicates an understanding of the teaching? A "The courts might require me to discuss confidential information." B "I am required to provide confidential information to insurance companies." C "If questioned during a police investigation, I am required to divulge confidential information." D "I am legally allowed to discuss confidential information with the client's former therapist."

A In some states, the court may enact a court order requiring the nurse to discuss confidential client information.

A nurse is caring for a client who has schizophrenia. Which of the following statments by the client indicates concrete thinking? A. "I am aware that each problem has only one solution." B. "I am a prophet of the most high king." C. "The voices tell me that I must avoid large crowds." D. "I know that you and the other nurses are trying to poison me."

A This statement is an example of concrete thinking which refers to the client's inability to think abstractly.

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignment for the client? A. A private room in a quiet location on the unit B. A semi-private room with a roommate who has a similar diagnosis C. A private room close to the nursing station D. A seclusion room until the client's activity level becomes more subdued.

A A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.

S/S of an adolescent female who has an eating disorder. Select all that apply A Amenorrhea B Verbalized desire to gain weight C Altered body image D Hyperactivity E Bradycardia

A C D E

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? A Dysrhythmias B Cataracts C Pancreatitis D Bleeding

A 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 providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statmenst indicates to the nrse that the client understands the teaching? A "I will take my dose of orlistat every morning an hour before breakfast." B "I will eat a no-fat diet to prevent side effects from the medication." C "I will stop taking orlistat and call my doctor if my urine gets darker in color." D "I will feel less hungry during meals while I am taking orlistat."

A Orlistat, a lipase inhibitor, is used as an aid to help clients who are morbidly obese to lose weight. Orlistat prevents the absorption of some of the fat in the client's dietary intake at each meal. Therefore, the client should take the medication 3 times daily, during or within 1 hr after the meal, not before the meal.

A nurse is providng discharge teaching to a pt who has bipolar disorder and will be discharged with a rx for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A The client runs 4 miles outdoors every afternoon. B The client drinks 2 liters of liquids daily. C The client eats 2 to 3 gm of sodium-containing foods daily. D The client eats foods high in tyramine.

A 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.

Medication to treat bipolar disorder (select all that apply) A Paroxetine B Lithium C Donepezil D Valproate E Carbamazepine

A, B, D, E

A nurse is caring for a client who has dementia. When performing a mental status examination (MSE) the nurse should include which of the following data? (select all that apply) A Ability to perform calculations B Level of consciousness C Recall ability D Long-term memory E Level of orientation

A, C, E

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 trats which of the following disorder? A Narcotic addiction B Vegetative depression C Personality disorder D Eating disorder

B ECT is an effective treatment for clients who have major depression, including clients who have vegetative findings.

A rn is observing a new RN as she interacts with a client regarding his concerns about his relationship with his partner. which of the following statements by the new RN requires intervention by the RN? A "Tell me about the concerns that you have regarding your relationship." B "You should try to see your partner's point of view before your own." C "We could develop a plan for how to talk about this with your partner." D "Relationship difficulties are stressful and require effort to resolve."

B This statement gives advice, which is nontherapeutic.

A RN is assessing a client who is experiencing alcohol withdrawal delirium. Which of the following findings should the nurse expect? A Severe hypotension B Visual hallucinations C Grandiosity D Paranoid delusions E Tremors

B C D E

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 mos. The client has a temp of 39.5C (103.4F), blood pressure of 150/110 mmhg, and muscle rigidity. Which of the following complication should the nurses suspect? A Agranulocytosis B Neuroleptic malignant syndrome C Akathisia D Tardive dyskinesia

B 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 is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "yester noon the sun moon went over the rover to see the lawnower." which of the following manifestation is the client exhibiting? A Delusional disorder B Associative looseness C Hallucination D Anhedonia

B The client who is manifesting associative looseness has ideas that do not connect to each other and are expressed in garbled and illogical speech. This is a typical disturbance for the client who has schizophrenia.

A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nrsing actions should the nurse take? A Praise the client for looking at herself in a mirror. B Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. C Reprimand the client about the potential damage that has occurred due to overexercising her body. D Restrict the client from being weighed.

B 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 is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following (select all that apply) A Urinary retention and constipation B Tongue thrusting and lip smacking C Fine hand tremors and pill rolling D Facial grimacing and eye blinking E Involuntary pelvic rocking and hip thrusting movements

B, D, E

A nurse is an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? A. Prepare for gastric lavage due to an extremely elevated lithium level. B. Administer of the morning dose of lithium C. Check the client's medication record to assess whether the client has been refusing her lithium. D. Hold the medication and assess for early manifestations of toxicity.

B. The nurse should administer the lithium dose since a lithium level of 1.0 mEq/L is within the expected initial therapeutic range of 0.8 to 1.3 mEq/L. At a therapeutic level the client might demonstrate adverse effects of lithium, such as a fine hand tremor, thirst, and mild nausea, and the nurse should note if any of these manifestations are present. The nurse should continue to monitor for adverse effects and signs of toxicity, which usually occur at levels of 1.5 mEq/L or higher

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take? A Encourage the client to go back to bed. B Give the client a PRN sleeping medication. C Remain with the client. D Explore alternatives to pacing the floor with the client.

C Remaining nearby the client will help to alleviate feelings of abandonment and reassures the client of his safety.

Which statement indicate cognitive distortion for an adolescent who has anorexia nervosa? A "I like to cut my food into small pieces." B "I really need to get into shape." C "If I eat one piece of candy, I may as well eat ten." D "I can't afford to gain weight."

C The client's statement is an example that displays all-or-nothing thinking, which is a form of cognitive distortion.

a RN is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, 'I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." which of the following response should the nurse make? A "Perhaps you could call your children to see how they are doing." B "Don't worry. We'll take good care of your parent while you are gone." C "You are feeling drawn in two separate directions." D "There's nothing you can do here. You should go home to your children."

C This response illustrates the therapeutic communication technique of restatement. This open-ended statement encourages further communication by the son.

A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. which of the following actions should the nurse take? A Discuss self-defense techniques with the client. B Inform the client photographs of injuries are required for a police report. C Ask the client to describe the situation. D Give the client a bed bath prior to physical examination.

C 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 is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instruction should the nurse give the client about the use of this medication? A Thyroid function tests should be performed every 6 months. B A pretreatment electroencephalogram (EEG) will be done. C Liver function tests must be monitored. D High serum sodium levels can cause toxic levels of valproate.

C Pancreatitis, hepatic dysfunction, and thrombocytopenia are serious adverse effects occasionally associated with valproate. Liver function tests should be monitored periodically to check for hepatic failure.

A school nurse is talking with a 13 yrs old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? A "My parents treat me like a baby sometimes." B "I haven't gotten my period yet, and all my friends have theirs." C "None of the kids at this school like me, and I don't like them either." D "There's a big pimple on my face, and I worry that everyone will notice it."

C This comment indicates the client might be at risk for depression, an eating disorder, or self-harm. Therefore, this comment is the priority for the nurse to address.

A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the client told, when a client who is schizophrenic jumps up and runs out of the room yelling, "you are all making fun of me!" the nurse should identify this behavior as which of the following characteristics of schizophrenia? A Magical thinking B Delusions of grandeur C Ideas of reference D Looseness of association

C When ideas of reference are present, the client believes all events, situations, or interactions are directly related to him.

A nurse in a mental health facility is planning care for a client who has OCD and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors? A Isolate the client for a period of time. B Confront the client about the senseless nature of the repetitive behaviors. C Plan the client's schedule to allow time for rituals. D Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

C. OCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels driven to perform. This behavior can be a physical action or a mental act that is aimed at neutralizing anxiety or distress. In the initial phase of treatment, the nurse should allow adequate time for the client to perform rituals to help the client handle anxiety.

a RN is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context? A The sense of self among individual family members B The future goals of the family C The roles of family members D The family's religious practices

D

A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A A room adjacent to the nursing station B A room without a window C A room with dim lighting D A room containing personal belongings

D A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment.

A nurse is caring for a client who professes a deep and everlasting love for his gf one day, and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of the following defense mechanism? A Repression B Splitting C Sublimation D Undoing

D The nurse correctly identifies this as an example of undoing which is the attempt to make up for or reverse prior behavior.

A RN is caring for a client who attacked one of her friends and is admitted to the psyc unit. Which of the following actions should the nurse take first? A Establish a client relationship. B Explain to the client that the behavior was unacceptable. C Explore the truth of the client's statements. D Set behavioral limits for the client.

D The nurse should first set behavioral limits for the client to stop harming others.

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? A Decreased auditory and visual acuity B Decreased display of emotions C Personality traits that are opposite of original traits D Forgetfulness gradually progressing to disorientation

D 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.

wHICH OF THE FOLLOWING IS THE MOST APPROPRIATE ROOM ASSIGNMENT FOR A NEW CLIENT WITH BIPOLAR DISORDER AND IS IN THE MANIC PHASE A. A semi-private room across from the day room. B A private room across from the nurse's station. C A private room across from the exercise room. D A semi-private room across from the snack area.

D The client should not be placed with a roommate because another client should not be subjected to the overactive behavior of the client in the manic phase and could stimulate the client in the manic phase. A client in the manic phase could over eat on snack foods if they were readily available.

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 response should the nurse make? A "Of course people care. Your family comes to visit every day." B "Why do you feel that way?" C "Tell me who you think doesn't care about you." D "I care about you, and I am concerned that you feel so sad."

D 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 is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? select all that apply A Avoid eye contact to prevent escalation of anxiety. B Establish rapport with the client. C Identify the cause of the anxiety. D Validate the client's feelings. E Develop a flexible crisis intervention plan.

b, c, d, e