Mental Health Unit 3

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?

"Do you feel afraid that people are trying to hurt you?"

A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client?

"Do you feel afraid that people are trying to hurt you?"

The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value?

"Do you recall what it was like before you started your medication?"

What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety?

"I can see that you are becoming upset."

The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time?

"I don't hear them, but it must be frightening to hear voices that others can't hear."

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?

"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis?

"I exercise 3 to 4 hours every day to keep my slim figure."

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder?

"I keep reliving the abuse."

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety?

"It must be frightening to think that others want to hurt you."

A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?

"When I have command hallucinations, I'll call a friend for help."

A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse?

"You will be safe here. Your thinking will be clearer after your medication starts to work."

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply.

1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 6.Magnetic resonance imaging shows temporal lobe atrophy

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply.

1.Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances

Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply.

1.Electrolyte levels 3.Intake and output 5.Elimination patterns

Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply.

1.Verbal communication is almost nonexistent. 3.The client needs frequent redirection because of short attention span.

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.

2."I keep reliving the robbery." 3."I see his face everywhere I go." 5."I might have died over a few dollars in my pocket."

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply.

2.Panic disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?

A client undergoing diagnostic tests

Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation?

A client with pneumonia

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing?

A. "Life isn't worth living if I gain weight."

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply.)

A. "What is your relationship like with your family?" C. "Would you describe your current eating habits?" E. "Can you discuss your feelings about your appearance?"

A nurse is caring for a client who has substance‑induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (Select all that apply.)

A. "When did you start hearing these things?" C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?"

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.)

A. Auditory hallucination C. Use of clang associations D. Delusion of persecution E. Constantly waving arms

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder?

A. Death of a child 2 months ago

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.)

A. Difficulty concentrating on tasks. C. Negative self‑image. D. Recurring nightmares

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury?

A. Install extra locks at the top of exit doors. D. Place the client's mattress on the floor. E. Install light fixtures above stairs.

A nurse is assessing a client who has illness anxiety disorder. Which of the following are expected for this disorder? (Select all that apply.)

A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers D. Depressive disorder

The nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action?

Assess the client for organic causes of the paralysis.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?

Atrophy of the lateral and/or third ventricles of the brain

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?

B. "I am no one, and everyone is me."

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?

B. "You should take this medication before going to bed at the end of the day."

A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply.)

B. Anxiety disorder C. Childhood trauma

A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

B. Ask the client, "Are you seeing something on the ceiling?"

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.)

B. Family report of personality changes C. Hallucinations E. Restlessness

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply.)

B. Hypokalemia D. Slightly elevated body weight

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first?

B. Initiate one‑to‑one observation of the client.

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma‑related disorder? (Select all that apply)

B. Take breaks during the incident for food and water. C. Debriefing with others following the incident. E. Take advantage of offered counseling.

A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another?

C. "I needed to make my child sick so that someone else would take care of them for a while."

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make

C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take?

C. Provide information on resources for respite care.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

C. The client states that the furniture in the room seems to be small and far away.

The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia?

Coffee, tea, and soda consumption should be limited

Which assessment finding would be a manifestation associated with dementia?

Confabulation

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?

Conversion disorder

A nurse in a long‑term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make?

D. "I am your nurse. Let's walk together to your room."

A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include?

D. Discuss alternative coping strategies with the client.

A nurse is planning care for a client who has anorexia nervosa with binge‑eating and purging behavior. Which of the following actions should the nurse include in the client's plan of care?

D. Implement one‑to‑one observation during meal times.

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect?

D. The client expresses a sense of unreality about the traumatic incident.

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?

D. Work with the client on grounding techniques.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride?

Dementia

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking 2 packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury?

Diminishing the effectiveness of psychotropic medication

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation?

During the entire family visit, the client presented with an expressionless, blank look.

During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia?

Eating a lot of food in a short period of time and misuse of laxatives

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?

Evidence of the client's disturbed body image

Which goal addresses the therapeutic management needs of a client experiencing hallucinations?

Facilitate the client's awareness that the hallucination is not the reality of the world.

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 plans care based on which purpose of this approach?

Helping the client to examine dysfunctional thoughts and beliefs

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor?

Impaired pain perception

The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention?

Including the client's support system in the teaching

Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving?

Increased number of hours slept at 1 time and is increasingly alert

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?

Interrupt the client and offer to take her for a walk.

The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority?

Interrupt the client, and offer to take her for a walk

During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with post-traumatic stress disorder?

Making the client feel safe

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?

Nutritional imbalance because of lack of intake

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

Observing rigid rules and regulations

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action?

Observing rigid rules and regulations

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support?

Post-traumatic stress disorder

The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking?

Present verbal instructions regarding expectations in single, simple commands.

The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care?

Provide assistance with grooming and nutrition until the client's thinking has cleared.

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget?

Share the observation with the client so the behavior can be recognized.

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?

Sit beside the client in silence with simple open-ended questions.

A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis?

Somatization disorder

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder?

Somatization disorder

During a mental status examination, the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." How will the nurse appropriately document the client's speech?

Speech is illogical and loosely associated.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect?

The client giggled while describing being physically abused as a child.

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli?

The client is convinced that the curtains are actually ghosts.

A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact?

The client regularly reexperiences the events associated with the assault.

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia?

The client's noncompliance with medication therapy

What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia?

Their child will be treated for an imbalance of the chemical dopamine.

An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury?

Turn off the television and radio, and use a night-light.

A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention?

Turn off the television.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?

Use of confabulation

The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency?

When asked to pick up the cup, the client consistently fails to identify the cup.

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study?

White blood cell count