MH2

A client with a history of major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

"Are you thinking of harming yourself?"

A client asks the nurse to give her information regarding the detoxification process of alprazolam. What is the best response from the nurse?

"Gradual downward tapering off this drug is necessary."

A client has been prescribed lithium for long-term maintenance of bipolar disorder. Which statement by the client shows an understanding of the medication?

"I need to be aware of situations that may cause dehydration.

A client with dementia asks her nurse, "Have you seen my husband?" The nurse is aware that the client's husband died several years ago. Which response by the nurse would demonstrate the use of validation therapy?

"Tell me about your husband.

A client has been prescribed lamotrigine for maintenance therapy of bipolar disorder. Which of the following statements by the client indicates an understanding of the education regarding lamotrigine

"I will need to notify my provider if I develop a rash."

A client who is delusional and paranoid refuses to take antipsychotic medication as prescribed. Which is the most therapeutic response by the nurse to this refusal?

"What is it about the medicine that you don't like?

. A client diagnosed with schizophrenia begins to talk about "cracklomers" in the local shopping mall. The word "cracklomers" should be documented as which term?

Neologism

. While caring for a client in a manic phase of bipolar disorder, the client has rapid-pressured speech and demonstrates flight of ideas. Which of the following would be the best response for the nurse to make

"I'm having a tough time following your train of thought."

A nurse is caring for a client brough into the emergency department by a friend who is concerned for the client's safety. Which of the following statements by the client would be a priority concern for the nurse

"My friend has a gun and I know where they keep it."

The nurse is teaching a client with schizoaffective disorder about the client's prescribed medication therapy. The nurse determines that additional education is needed when the client states which of the following?

"One day, I won't have to worry about taking any medications."

A family member is the primary caregiver to a client with dementia. Which statement by the nurse would be most appropriate?

"Spending some time relaxing and doing what you like to do will help you manage the demands of caregiving."

A 29-year-old female client has recently been diagnosed with bipolar disorder and has been prescribed valproic acid. What teaching must be provided to the client regarding the medication

"You will need to ensure you are using a form of birth control when sexually active."

The nurse is caring for a client in the prodromal phase of schizophrenia. What behaviors should the nurse expect to observe?

. A decline in level of functioning

A 45-year-old client with bipolar disorder is admitted to the psychiatric unit for management of manic symptoms. The client has been receiving high-dose haloperidol for the past three days. On assessment, the nurse notes fever, diaphoresis, tachycardia, and lead-pipe rigidity. What would the nurse prioritize in the client's plan of care?

. Discontinuing all antipsychotic medications and providing supporting care.

A client diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). What client teaching should be a priority for the nurse

. Discuss expected short term memory loss with client and family.

A client tells a nurse that their voices are telling him to do "terrible things." What is the best action by the nurse?

. Find out what the voices are telling him.

. A client has been prescribed several antipsychotics to help relieve symptoms. Most recently, the client has been prescribed a first-generation antipsychotic. The nurse understands that this medication will treat which of the following symptoms the client is experiencing?

. Hallucinations

A client with acute mania approaches the nurse, waves a newspaper, and says, "I must make a phone call right this minute. I need to call a store while their sale is going on. I need to order 10 dresses and four pairs of shoes." Which of the following would be the most appropriate intervention for the nurse to implement?

. Invite the patient to sit with the nurse and look at new fashion magazines as a distraction

A client has been taking risperidone for a few months and is exhibiting these signs and symptoms upon admission: high fever, muscle rigidity, tachycardia, and a decreased level of consciousness. Which adverse effects do these symptoms best describe?

. Neuroleptic malignant syndrome

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect

. Presence of symptoms for at least two years

1. One of the primary goals in caring for the client with schizophrenia is to establish clear, consistent, open communication. Which nursing intervention would be most effective in accomplishing this goal?

. Present reality in clear, simple language, and demonstrate patience

The nurse is caring for a client who has been ordered to receive phototherapy to treat depression. The nurse recognizes this is a treatment for which of the following disorders?

. Seasonal affective disorde

A client is admitted to the hospital for abdominal pain, diarrhea, sweating, fever, tachycardia, and elevated blood pressure. Upon review, the client has been taking sertraline, but the client states they were recently switched from another medication, phenelzine. Which of the following does the nurse most likely suspect the client is experiencing?

. Serotonin syndrome

The 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?

. The client states someone is telling him to die

The client admitted to the psychiatric unit diagnosed with schizophrenia is prescribed clozapine. Which of the client's laboratory data should the nurse evaluate first?.

. White blood cell count

. A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what results?

1.0 mEq/L

. A nurse is providing care to a client who recently started taking haloperidol for treatment of schizophrenia. The client comes to the nurses' station frightened and panicked. The client's eyes are locked into a position looking up and to the right. The nurse recognizes the client is experiencing which type of side effect

Acute dystonia

. During the admission process, an elderly client is asked to present their driver's license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?

Agnosia

A nurse is caring for a client who takes olanzapine for psychosis and reports a perpetual sense of restlessness and an inability to sit still. He says, "Sometimes it gets so bad I want to jump out of my own skin." The nursing recognizes the client is most likely experiencing which symptom?

Akathisia

A client sustained a sprained ankle following a skiing accident while intoxicated. The client has a long history of chronic alcohol misuse. The health care provider has ordered the client to remain in the hospital for observation. The spouse requested the client be released and said, "My spouse will be able to sleep better at home." Which of the following rationales will the nurse use to support the hospital stay?

Alcohol withdrawal can be a serious, including the risk for seizures and death.

A nurse is caring for a client diagnosed with major depressive disorder. Which nursing intervention would be appropriate for the nurse to include during the intake interview

Allow the client time to respond to questions.

. A client with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the client?

Allowing the client supervised access to food vending machines.

A client is describing to the nurse that in the past several months they have not gone to their monthly bridge game. The client states, "I just don't see the point in going, it doesn't make me happy anymore." The nurse recognizes this is which symptom of depression

Anhedonia

. The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. Which of the following is the most appropriate follow-up assessment based on this information?

Ask the patient if he is hearing something or someone other than the nurse's voice

A client is being discharged home on tranylcypromine. The nurse includes which information as part of the discharge instructions?

Avoid substances containing tyramine, tryptamine, or tryptophan."

. A client has a history of schizophrenia, controlled by haloperidol. During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the provider to prescribe for this client?

Benztropine mesylate

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

CIWA Assessment

. A nurse is caring for a client with an alcohol use disorder. The nurse will anticipate the healthcare provider to order which medication to help lessen the risk for alcohol withdrawal while the client is in treatment?

Chlordiazepoxide

Which of the following potential physical complications are most likely to develop in a client dependent on alcohol? (Select All the Apply

Cirrhosis b. Lip smacking Pancreatitis

A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90 mm Hg, pulse is 110 beats/minute, and respirations are 22 breaths/minute. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which condition to be occurring?g

Delirium tremens

During group therapy a client asks, "Is there a medication I can take to help me from relapsing after I have completed my alcohol rehabilitation program. I am not sure I can be as confident when on my own as I am while here in the rehabilitation center." What medication will the nurse discuss with the client?

Disulfiram

The nurse documents that a client diagnosed with schizophrenia is experiencing anticholinergic side effects from long term use of thioridazine. Which symptoms has the nurse noted

Dry mouth, constipation, and urinary retention

6. Family members of an alcoholic client ask the nurse to help them with conduct an intervention session. Which action is essential for a successful intervention?

Each family member needs to tell the client how the addiction has affected them

. A nurse is assessing a client with schizophrenia who has been taking risperidone for one year. The nurse notices that the client has grimacing and fine tongue movements. What do these symptoms most likely indicate?

Early symptoms of tardive dyskinesia (TD)

The nurse states, "It's time for lunch." A client diagnosed with schizophrenia responds, "it's time for lunch, lunch, lunch." The nurse recognizes this as which symptom of speech alteration

Echolalia

A nurse is assessing a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal?

Hallucinations

A client in a manic phase of bipolar disorder is unable to sit still during the lunch hour. Which of the following would be the best option to meet the needs of the client?

Ham sandwich and cheese stick

. A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food but doesn't pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try first?

Hand the fork to the client and say, "Use this fork to eat the meatloaf."

Which behavior is a priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder?

Hyperactivity, dismissing meals, and sleep disturbance

. A 37-year-old client with a history of schizophrenia has been taking aripiprazole for several weeks. The client presents to the emergency department with high fever, altered mental status, muscle rigidity, and decreased level of consciousness. Which action will the nurse prioritize in the care of the client?

Initiating cooling measures to lower the client's temperature

A nurse is teaching a group of clients regarding the use of naltrexone in treating alcoholism. What would the nurse teach about the effectiveness of this drugs

It reduces the craving for alcohol

A patient with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." Which of the following best describes the nursing action while actively listening to this patient?

Maintain at least an arm's length from the patient.

A newly admitted client has a diagnosis of catatonic schizophrenia. Which behavior observed in the client supports the diagnosis?

Maintains an immobilized state for hours

A 27-year-old woman has a 4-month-old baby. For the past 3 months, the client has been experiencing intense sadness, anxiety and hopelessness. After having thoughts of killing her baby, she decided to seek help. The nurse anticipates which of the following psychiatric disorders?

Postpartum depression

A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

Provide a well-lit room without glares or shadows with minimal noise

The nurse develops a nursing care plan for a client who is in the manic phase of bipolar disorder. Which intervention does the nurse include in the plan of care?

Provide the client with finger-foods

A nurse is preparing to discharge a client recently diagnosed with schizophrenia who was started on olanzapine. Which nursing intervention is essential to promote medication adherence in a client with schizophrenia?

Providing education about medication compliance and possible relapse.

. A client diagnosed with depressive disorders begins taking paroxetine as part of their medication therapy. The nurse should provide which information to the client and family?

Report increased suicidal thinking

. A client's family states their son hallucinates, has delusions, and has been withdrawn with a flat affect. The nurse anticipates the provider will order which medication to treat the client's symptoms

Risperidone

Which of the following drugs is prescribed for treatment of Alzheimer's dementia?

Rivastigmine

A client diagnosed with major depressive disorder began taking nortriptyline one week ago. During a follow-up visit, the client states, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." Which of the following actions would be most appropriate for the nurse at this time

Teach the client strategies to manage postural hypotension.

An 80-year-old client, together with his daughter, arrived at hospital for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

The change in his behavior came on so quickly! I wasn't sure what was happening."

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

The client becomes suddenly cheerful.

The nurse documents that a client diagnosed with schizophrenia is expressing a flat affect. What is an example of this symptom?

The client exhibits no emotional expression.

The nurse is caring for a client receiving lithium therapy for mood stabilization. The client is experiencing tremors, vomiting, and ataxia. Which of the following findings in the client's history supports the diagnosis of lithium toxicity?

The client has been training for a marathon.

. A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. Which of the following is an example of a client using confabulation?

The client makes up stories when unable to recall actual events

. A client diagnosed with vascular dementia is discharged to home under the care of his spouse. Which information causes the nurse to question the client's safety?

The client smokes one pack of cigarettes per day.

An older adult client is experiencing delirium caused by fever and dehydration. Which of the following is the most appropriate desired outcome for the client?

The client will return to pre-illness levels of functioning.

The nurse is preparing to discharge a client home and is educating the family regarding the new medication of rivastigmine. Which of the following statements by the family member indicates the need for further teaching?

This medication will stop the progression of the disease."

A nurse on a crisis hotline is speaking to a client who says, "I just refilled my script and took an entire bottle of amitriptyline." The nurse sends immediate medical attention due to which of the following reasons?

Tricyclic antidepressants are known to be fatal in overdose.

The nurse caring for an elderly client with dementia has asked the client's children to bring old photo albums when they visit. The nurse observes the actions of the client as the client talks about the photos. Which best describes the usefulness of viewing photos when caring for a dementia client?

Viewing photos is a form of reminiscence therapy for the client.

A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and go to my barber. I see them every Wednesday. Let me out!" Which of the following would be the most therapeutic response by the nurse?

You are in the hospital, and I'm your nurse."

What are the possible physiological changes in the brain of a client diagnosed with Alzheimer's disease? (Select all that apply

a. Brain atrophy *b. Overabundance of plaques (amyloid beta) *c. Overabundance of tangles (tau protein)

. A client with schizophrenia has been prescribed olanzapine as part of the treatment plan. The nurse recognizes the need to monitor which of the following while the client is taking the medication? (Select All that Apply)

a. Hyperglycemia *b. Sedation Weight gain