MH practice B NGN

a client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. the client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." which of the following actions should the nurse take?

move the client who has bipolar disorder to a private room.

a nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. which of the following manifestations of this disorder should the nurse include in the teaching?

language delay

a nurse is planning care for a client who has generalized anxiety disorder. at which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

mild

a nurse is assessing a client for risk factors for the development of depression. the nurse should identify that which of the following factors places the client at an increased risk for depression?

the client has COPD

a nurse is caring for a client who gave birth to a stillborn baby. which of the following statements should the nurse make?

Ill stay with you just in case you want to talk

a nurse is receiving change-of-shift report for four clients. which of the following clients should the nurse plan to see?

a client who is taking clozapine and reports a sore throat and chills

the nurse is providing teaching to a client. which of the following statements should the nurse include in the teaching?

"You should seek help if you have thoughts of self-harm." "It is common for people who survived a traumatic event to experience feelings of anxiety." "A support group might be helpful to you during this time."

a nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. available is diazepam injection 5mg/mL. how many mL should the nurse administer?

1.5mL

a nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. which of the following statements by the client indicates acceptance of illness?

I am going to order a wheelchair for when I'm unable to walk

a nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. the nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?

I will not take charge of my partner's work responsibilities.

a nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. which of the following statements by the client indicates an understanding of the teaching?

I will talk about my feelings with a close friend.

a nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I will update the plan of care as aa client's manifestations of depression change.

a nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" which of the following responses should the nurse make?

Let's talk about what is upsetting you.

a nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. which of the following values should the nurse identify as a contraindication for receiving clozapine?

WBC count 2,500/mm3

a nurse is planning discharge teaching for a client who has severe schizoaffective disorder. the nurse should identify that which of the following treatments options can offer interdisciplinary services for the client at home?

assertive community treatment

a nurse is caring for four clients in an emergency department. the nurse should identify that which of the following clients can give informed consent?

a 35-year-old client who has major depressive disorder

a nurse on an acute mental health facility is receiving change-of-shift report for four clients. which of the following clients should the nurse assess first?

a client who is experiencing delusion of persecution

a nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. the nurse should administer benzotropine to relieve which of the following adverse effects?

acute dystonia

a nurse in the emergency department is caring for four clients. which of the following clients is the nurse required to report as a potential victim of abuse?

an older adult client who is bed bound and has a stage IV pressure ulcer

for each potential provider's prescription, click to specify the potential prescription is anticipated, nonessential or contraindicated for the client.

apply restraints; contraindicated. urinalysis; anticipated. insert catheter; contraindicated. melatonin; anticipated. MRI; nonessential. IV fluids; anticipated

a nurse on a medical-surgical unit is assessing a cite who sustained injuries 12hr ago following a motor-vehicle crash. the client's admission blood alcohol level was 325mg/dL. which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

blood pressure 154/96 mm Hg

a nurse on a mental health unit observes a client who has acute mania hit another client. which of the following actions should the nurse take first?

call for a team of staff members to help with the situation

the nurse is caring for the client, who is in seclusion and under mechanical restraints. for each potential assessment finding, click to specify if the findings indicates the client's condition has improved, not changed, or has declined.

client attempts to bite staff; declined. client follows instructions; improved. silent and glaring; not changed. client verbalizes precipitating factors; improved.

a charge nurse on a mental health unit is discussing client rights with a client newly licensed nurse. which of the following statements should the charge nurse make?

clients who are admitted involuntarily maintain the right to give informed consent for procedures.

which of the following findings should the nurse report to the provider immediately? select the 5 findings the require immediate follow-up.

cognitive awareness, blood pressure, sleep/wake cycle, I&O, temp

a nurse in a mental health facility is caring for a client who has schizophrenia. which of the following findings places the client at the greatest risk for self-directed injury or injuring others?

command hallucinations

the nurse is caring for the client. which of the following actions should the nurse take? SATA

continuous observation, debriefing with the client and other staff.

a nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. which of the following assessments findings supports the nurse's suspicion of delirium?

easily distracted

a nurse is planning prevention strategies for partner violence in the community. which of the following strategies should the nurse include as a method of secondary prevention?

establish screening programs to identify at-risk clients.

a nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. which of the following outcomes should the nurse expect?

greater risk of attempting suicide as affect and energy improve

a nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. which of the following interventions should the nurse include to reduce anxiety among the group members?

guided imagery

for each potential nursing intervention, click to specify potential intervention is anticipated, nonessential, or contraindicated for the client.

haldol IM anticipated. hold buspirone; contraindicated. request change of diet; nonessential. digoxin IV bolus stat; contraindicated. calmly approach client; anticipated.

a nurse is assessing a client who is displaying manifestations of delirium. which of the following information from the client's medical record are risk factors of delirium?

hospital environment, client's age, postoperative, fever

a nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. which of the following actions is the first component of a safety plan?

identify signs of escalation of violence

a nurse is updating the plan for a client who has bulimia nervosa and is 5% above their ideal body weight. which of the following interventions should the nurse include in the plan?

identify the client's trigger foods

the nurse is evaluating the client's response to treatments. for each assessment finding, click to specify if the findings is an improvement, no change, or a decline in the clients condition.

improvement; vital signs, daytime orientation, I&O, pain level. no change; sleep/wake cycle, glucose. decline; ambulation

a nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. which of the following findings should the client's partner report to the provider?

inability to sleep

a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. to establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

inform the client that this admission is confidential

a nurse observes a client on a mental health unit pushing on the locked unit door. which of the following statement should the nurse make?

it appears as though you would like to open the door

a nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. which of the following statements made by the guardians indicates an understanding of their child's illness?

it is important for our child to have regular dental checkups

a nurse is planning care for a client who has made repeated physical threats toward others on the unit. although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. which of the following ethical principles should the nurse apply in this situation?

nonmaleficence

a nurse is preparing to discharge to home an older adult client who attempted suicide. the client lives alone and has difficulty performing ADLs. which of the following referrals should the nurse initiate? SATA

occupational therapy, meal delivery services, physical therapy, home health services

the nurse is caring for the client. which of the following actions should the nurse take for this client?

offer the client warm milk at bedtime, maintain a low-stimulation environment for the client. approach the client from the front and speak slowly

a nurse is assessing a family's dynamics during a counseling session. the nurse should recognize which of the following findings as an indication of a boundary issue?

older children who are responsible for their younger siblings

a nurse is caring for an older adult client who is experiencing delirium. which of the following interventions should the nurse include in the client's plan of care?

permit the client to perform daily rituals to decrease anxiety

a nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

phenylephrine

a nurse is evaluating the client after 2 weeks. which of the following findings indicate an improvement in the client's condition?

potassium, sodium, BMI, heart rate

a nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. which of the following therapeutic nursing interventions is the priority?

reduce environmental stimuli

a nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. which of the following interventions should the nurse include in the plan?

renew the prescription for the client every 4hr

a nurse on a mental health unit is caring for a group of clients. which of the following actions by the following actions by the nurse is an example of the ethical principle of justice?

spending adequate time with a client who is verbally abusive

a nurse in a mental health clinic is planning care for four clients. which of the following tasks should the nurse delegate to an assistive personnel?

stay with a client who has anorexia nervosa for 1 hr after mealtimes.

select the 6 findings found in the client's medical record that are manifestations of the client's diagnosed personality disorder.

stealing money from family to cover credit card charges, anxious if left alone, hypersexualization, married multiple times, incidences of self-injury, physical altercations

a nurse is talking with a group of parents who have recently experienced the death of a child. which of the following actions should the nurse take?

suggest forming a weekly support group for parents who have experienced the death of a child.

for each potential provider's prescription, click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder. each therapy can support more than one disease process.

systematic desensitization; OCD validation therapy; dementia. dialectal behavior therapy; BPD donepezil; dementia fluoxetine; OCD and BPD

a nurse is caring for a child who is taking methylphenidate. the nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?

tachycardia

complete the following sentence by using the lists of options

the client is at risk for developing violent behavior as evidenced by the client's increased agitation

a nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. which of information should the nurse include in the teaching?

the client should obtain a sponsor before discharge for an increased chance of recovery.

the nurse is planning care for the client who has delirium and new prescriptions. complete the following sentences by using the lists of options.

the nurse should first initiate IV fluids followed by administering acetaminophen.

a nurse is assessing a client who has bulimia nervosa. the nurse should expect which of the following findings?

tooth erosion

a nurse at a provider's office is interviewing an older adult client. which of the following actions should the nurse plan to take?

use a screening tool to evaluate the client for depression