Mental Health
A nurse is reinforcing teaching with a client about a new prescription for lithium. Which of the following statements should the nurse include in the teaching? 1. "Your lithium will be discontinued in 6 months to prevent addiction" 2. "Weight gain is a manifestation of lithium toxicity" 3. "Your provider will prescribe a diuretic while you are taking lithium" 4. "We will need to check your lithium levels in the next 3-5 days"
"We will need to check your lithium levels in the next 3-5 days"; the medication has a narrow therapeutic range and it is recommended to check lithium levels within the first 5 days of beginning of treatment and possibly twice weekly until maintenance dosage is reached.
A nurse is collecting data from a client who is to begin taking alprazolam. Which of the following findings should the nurse identify is a contraindication to this medication? 1. Alcohol use disorder 2. Drug withdrawal 3. Seizure disorder 4. Suicide attempts
Alcohol use disorder; benzodiazepines are contraindicated in clients who have alcohol use disorder due to the risk for CNS depression.
A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect? (SATA) - Amenorrhea - Altered body image - Erosion of teeth - Hypokalemia - Tachycardia
Amenorrhea, Altered body image, Hypokalemia
A nurse is collecting data from a client who has a depressive disorder. The client states, "I just can't feel any happiness of joy in life." Which of the following terms should the nurse use when documenting? 1. Anhedonia 2. Anergia 3. Anosognosia 4. Akathisia
Anhedonia; refers to inability to experience pleasure or joy.
A nurse is contributing to the plan of care for a client who has OCD regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority? 1. Assist the client in identifying his anxiety level 2. Speak to the client in a calm and soothing manner 3. Assist the client to identify triggers to obsessive behaviors 4. Provide info on stress reduction methods
Assist the client in identifying his anxiety level; interventions to prevent escalation of the client's anxiety and maintain the safety of the client can be determined based upon this finding.
A nurse is caring for a client who has Alzheimer's disease. The client states, "I just came back from a hard day's work in my office." The nurse should identify this statement is an example of which of the following coping mechanisms? 1. Perseveration 2. Confabulation 3. Thought deletion 4. Tangentiality
Confabulation; the creation of information which is untrue to fill in gaps in memory and to protect self-esteem in client who have dementia.
A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect? 1. Tachycardia 2. Constipation 3. Metrorrhagia 4. Hyperkalemia
Constipation; due to starvation
A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates the medication is effective? 1. Increase in weight 2. Increase in urinary output 3. Decrease in hallucinations 4. Decrease in urge to smoke
Decrease in urge to smoke; antidepressant that is also used for smoking cessation.
A nurse is reviewing the lab reports of a client who has bipolar disorder and notes a serum lithium level of 2.0. Which of the following actions should the nurse take? 1. Determine vital signs 2. Continue to monitor the client q2h 3. Decrease the client's fluid intake 4. Request the laboratory repeat the test the next morning.
Determine vital signs; the lithium level is indicative of toxicity. The nurse should check vital signs, mental status, and other possible manifestations of toxicity. The nurse should notify the provider immediately.
A nurse is reinforcing teaching about valproate with a client who has a bipolar disorder. Which of the following information should the nurse include in the teaching? 1. Thyroid function tests performed every 6 months 2. Pretreatment EEG will e performed 3. Liver function tests must be monitored regularly 4. A white blood count must be monitored weekly
Liver function tests must be monitored regularly; hepatotoxicity is rare but is a serious adverse effect.
A nurse is collecting data from a client who has generalized anxiety disorders. Which of the following findings should the nurse expect in this client? 1. Sleeps 11-12 hr/night 2. Seeks reassurance from others 3. Makes impulsive decisions 4. Exhibits constant hair pulling or skin picking
Seeks reassurance from others; due to difficulty with decision-making, the client frequently seeks reassurance from fiends and family members.
A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (SATA) - Talking in rapid, continuous speech - Interacting with others in a flirtatious way - Reports spending large sums of money - Reports sleeping for long periods of time - Exhibiting clang associations
Talking in rapid, continuous speech, Interacting with others in a flirtatious way, Reports spending large sums of money, Exhibiting clang association
A nurse is caring for four clients in an acute care mental health facility. The nurse should recognize which of the following clients as a potential candidate for electroconvulsive therapy (ECT) as an effective treatment option? 1. A client who has severe opioid use disorder 2. A client who has bipolar disorder with rapid cycling 3. A client who has long-standing antisocial personality disorder 4. A client who has anorexia nervosa with electrolyte imbalances
A client who has bipolar disorder with rapid cycling; rapid cycling is the presence of 4 or more episodes of mania in a year.
A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide? 1. a client with OCD and takes fluoxetine 2. a client who has generalized anxiety disorder and takes diazepam 3. a client who has social anxiety disorder and takes propranolol 4. a client who has generalized anxiety disorder and takes diphenhydramine
A client with OCD and takes fluoxetine; adverse effect of SSRI antidepressant is increased risk for suicide.
A nurse in an acute care mental health facility is caring for a hospitalized client who has agoraphobia. The nurse observes that the client is making progress when he is able to participate in which of the following activities? 1. Recreational therapy in the day room 2. Daily group therapy sessions 3. A picnic in a local park 4. Lunch in the hospital cafeteria with family
A picnic in a local park; agoraphobia is fear of being in places where help might not be available, such as being outside alone.
A nurse is reinforcing teaching with a client who has a prescription for nortriptyline. Which of the following client statements indicates an understanding of the teaching? 1. "I may experience an increased libido" 2. "I can no longer eat pepperoni pizza" 3. "I will avoid drinking caffeinated beverages" 4. "I should sit on the side of the bed before standing up in the morning"
"I should sit on the side of the bed before standing up in the morning"; Nortriptyline can cause orthostatic hypotension.
A nurse is caring for a 20-year-old college student who has a 2 year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse? 1. "It seems like you are feeing helpless about this behavior" 2. "Do you have any idea why you do this?" 3. "I'm proud of you for recognizing that this behavior is not normal" 4. "You should stop because you need to. You are destroying your health"
"It seems like you are feeling helpless about this behavior"; the nurse is responding the feelings the client has expressed.
A nurse is reinforcing teaching with a client who is scheduled ro receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching? 1. "You might feel a bit confused and disoriented when you first wake up" 2. "You may experience muscle cramping from the induced seizure" 3. "You should expect to have ECT once per week for 6 weeks" 4. "The most common adverse effects of ECT are related to the anesthesia"
"You might feel a bit confused and disoriented when you first wake up"; the usual schedule of ECT treatment is 2-3 treatments per week for 6-12 months
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching? 1. "You should change positions slowly while taking this medication" 2. "This medication is prescribed to help overcome alcohol use disorder" 3. "You should expect an increase in urine output" 4. "This medication may cause increased salivation"
"You should change positions slowly while taking this medication"; risk of orthostatic hypotension. Used to treat depressive disorders. May cause urinary retention. May cause dry mouth.
A nurse is reinforcing teaching with a client who is to begin taking a MAOI in addition to a SSRI. Which of the following statements should the nurse include in the teaching? 1. "You should slowly increase your MAOI dose to prevent adverse effects" 2. "You will need to be off the SSRI for at least two weeks before starting the MAOI" 3. "You can take half the dose of the SSRI while you are taking the MAOI" 4. "You can expect to experience a temporary increase in anxiety while taking both and MAOI and an SSRI"
"You will need to be off the SSRI for at least two weeks before starting the MAOI"; to avoid serotonin syndrome, the client needs to be off all SSRI medications for 2-5 weeks before initiating MAOI.
A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium? 1. A client wants to know what type of poison the nurse placed in her medication 2. A client asks when family members will be arriving after visiting 1 hour earlier 3. A client requests extra blankets when the thermostat in the room indicates 80 degrees 4. A client expresses dislike of orange juice after reporting earlier that it was a favorite juice.
A client asks when family members will be arriving after visiting 1 hour earlier; delirium is characterized by a change in cognition that occurs over a short period of time, alterations in memory, agitation, restlessness, illusions, or hallucinations.
A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). Which of the following medications should the nurse plan to administer prior to ECT therapy? 1. Atropine sulfate 2. Phenytoin 3. Topiramate 4. Digoxin
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A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse includes which of the following? (SATA) - Ability to perform calculations - Level of consciousness - Presence of suicidal thoughts - Long-term memory - Level of orientation
Ability to perform calculations, Level of consciousness, Presence of suicidal thoughts, Level of orientation.
A nurse is assisting with the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse recommend to include? 1. Provide a stimulating environment 2. Encourage short rest periods throughout the day 3. Encourage group activities 4. Schedule daily seclusion times
Encourage short rest periods throughout the day; the client might not be aware of developing fatigue from hyperactivity. The client is at risk for injury without sufficient rest.
A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse include? 1. Avoid foods that contain tyramine 2. Plan to discontinue as soon as your depression is relieved. 3. Expect that your mood might take one to three weeks to begin improving. 4. Stop taking this medication if weight loss or gain occurs.
Expect that your might might take one to three weeks to begin improving; therapeutic response may not be experienced for 1-3 weeks and full therapeutic effects may take up to 12 weeks.
A nurse is planning to meet with a client for the first time to start developing a helping relationship. Which of the following actions should the nurse take during the orientation phase? 1. summarize goals the client achieved 2. formulate a contract 3. gather further data 4. promote the client's self-esteem
Formulate a contract; identifies the nurse's and client's responsibilities during the relationship. Includes where they will meet, how frequently, and for how long.
A nurse in a long-term care facility is performing a mental status examination (MSE) for a newly-admitted client who has dementia. Which of the following data should the nurse include? (SATA) - Grooming - Long-term memory - Support system - Affect - Presence of pain
Grooming, Long-term memory, Affect; MSE consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.
A nurse in an acute care mental health facility is caring for a client who commits suicide. Which of the following is the priority intervention for staff following this incident? 1. Attending a counseling session for staff members who provided care for the client/ 2. Encouraging other clients on the unit to talk about their feelings regarding the suicide. 3. Identifying cues in the client's behavior that might have warned staff that he was contemplating suicide. 4. Recommending resources for the client's family to help them deal with their grief.
Identify cues in the client's behavior that might have warned staff that he was contemplating suicide.
A nurse is collecting data from a client who has agoraphobia. Which of the following prescriptions should the nurse anticipate the provider will prescribe? 1. Imipramine 2. Haloperidol 3. Verapamil 4. Bromocriptine
Imipramine; TCA that is effective in diminishing symptoms of agoraphobia. Haloperidol is an antipsychotic, Verapamil is a calcium-channel blocker, Bromocriptine is an anti-Parkinsonian.
A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage? (SATA) - Inability to find commonly used items - Inability to perform common tasks - Exhibits wandering behaviors - Difficulty remembering how to swallow - Inability to recognize family members
Inability to perform common tasks, Exhibits wandering behavior.
A nurse at a mental health facility is discussing antidepressant medications with a newly licensed nurse, comparing SSRIs and tricyclic antidepressants (TCAs). Which of the following info should the nurse include about TCAs? 1. Less effective in relieving depressive symptoms 2. Low probability of causing sedation 3. More likely to be prescribed as initial treatment 4. Increased risk of cardiovascular adverse effects.
Increased risk of cardiovascular adverse effects; can cause dysrhythmia and be lethal to the client in the event of overdose. Cardiac screening before beginning therapy. Sedation is a common adverse effect.
A nurse is assisting with the admission of a client who has bipolar disorder and is experiencing an acute depressive episode. Which of the following prescriptions should the nurse anticipate receiving from the provider? 1. Amitriptyline 2. Lithium carbonate 3. Phenelzine 4. Mirtazapine
Lithium carbonate; antipsychotic mood stabilizer. First-line treatment for clients who are experiencing an acute depressive episode of bipolar disorder.
A nurse is caring for a client who is exhibiting signs of serotonin syndrome. Which of the following is the nurse's priority intervention? 1. Administering anticonvulsant 2. Administering diazepam 3. Preparing for artificial ventilation 4. Applying a cooling blanket
Preparing for artificial ventilation
A nurse is collecting data from a newly admitted client who has major depressive disorder. Which of the following findings should the nurse expect? 1. Psychomotor retardation 2. Ritualistic behaviors 3. Impulsivity 4. Clang associations
Psychomotor retardation; slowed movements, thoughts, and speech are common in the client who has major depression.
A nurse is caring for a client who has depression and a new prescription for bupropion. The nurse should collect data from the client regarding which of the following contraindications for taking bupropion? 1. Recent head trauma 2. Current elevated cholesterol levels 3. History of thyroid disease 4. History of glaucoma
Recent head trauma; seizures are a major adverse effect of bupropion. History of seizure disorders, head trauma, or cranial tumor is contraindicated. History of eating disorder also increases seizure risk.
A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take? 1. Reinforce how to use assertive communication techniques 2. Schedule the client's daily self-care activities 3. Set short-term and long-term goals for the client. 4. Discourage the client from expressing anger.
Reinforce how to use assertive communication techniques; can improve the client's self-esteem and increase a sense of control. Client should make their own schedule of self-care activities.
A nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. Which of the following interventions should the nurse include in the plan? 1. Restrict the client's sodium intake 2. Encourage the client to eat three large meals per day 3. Weight the client weekly 4. Observe the client for 1 hour after they eat
Restrict the client's sodium intake; the client is at risk for ascites. Sodium increases the risk for fluid retention.
A nurse in an acute mental health unit is assisting with the admission of a client who has bipolar disorder. Which of the following findings indicates that the client is experiencing acute mania? 1. The client's partner reports that the client has recently gained weight 2. The client is dressed in all black 3. The client responds to questions with disorganized speech 4. The client reports that voices are telling him to write a novel.
The client responds to questions with disorganized speech; clients experiencing acute mania exhibit disorganized speech such as flight of ideas.
A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms? 1. Repression 2. Splitting 3. Sublimation 4. Undoing
Undoing; an example of denial which is escaping unpleasant or anxiety-causing thoughts or feelings by ignoring their existence. Repression: unconsciously forgetting. Splitting: inability to combine positive and negative qualities. Sublimation: unconsciously substituting unacceptable impulse with one that is acceptable.
A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching? 1. Vomiting and diarrhea 2. Increased flatulence 3. Loss of appetite 4. Increase urination
Vomiting and diarrhea; early manifestations of lithium toxicity include diarrhea, lethargy, impaired coordination, muscle weakness, nausea or vomiting, slurred speech, and trembling. The client should omit the next dose and call the provider.
A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take? 1. Withhold the medication 2. Re-check the client in 4 hours 3. Administer the next dose as prescribed 4. Encourage the client to rest with his eyes closed
Withhold the medication; early signs of lithium toxicity can be detected by assessing for nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, and find hand tremors.
