Nursing 4530 - MH- PREP U - (Study B)
When the nurse is obtaining a health history on an elderly client who has had a previous myocardial infarction, the daughter states, "I have been giving my father ginkgo biloba every day, as he is beginning to have some memory loss." How does the nurse respond to the daughter's statement?
"How much of the herbal drug are you giving your father every day?"
At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine even though it controls his symptoms of schizophrenia better than other medications. "I have gained 20 lb (9.1 kg) already. I cannot stand anymore." Which response by the nurse is most appropriate?
"I can help you with a diet and exercise plan to keep your weight down."
After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which of the following would confirm that the client is developing insight into his illness?
"I didn't realize how sick I could get from a chemical brain imbalance."
A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic?
"I don't hear the voice, but I know you hear what sounds like a voice."
A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse's teaching about this medication?
"I need to keep my appointment here at the clinic this week for a blood test."
While pacing in the hall, a client with schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?
"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."
75. A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I have got to go see my doctor. I just cannot miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate?
"It is 5 o'clock Tuesday, and you are in the hospital. I am Anne, a nurse."
The client with dementia states to the nurse, "I know you. You are Margaret, the girl who lives down the street from me." Which response by the nurse is most therapeutic?
"Mrs. Jones, I am Rachel, a nurse here at the hospital."
A client diagnosed with schizophrenia is being switched to risperidone long-acting injection. He is told that he will remain on his oral dose of risperidone daily for approximately 1 month. The client says, "I did not have to take pills when I was on fluphenazine shots in the past." The nurse should tell the client:
"Risperidone long-acting injection initially takes a little longer to reach the ideal blood level."
Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which of the following responses by the nurse would be most appropriate?
"Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood."
After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent:
"What concerns do you have about vaccinations?
A client with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?
"You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."
A client diagnosed with schizophrenia gained 50 lb (22.7 kg) in 6 months while taking olanzapine. After a prescription change from olanzapine to ziprasidone, the client tells the nurse, "I do not want to take this ziprasidone either. I cannot gain any more weight." Which response by the nurse is most appropriate for this client?
"Ziprasidone causes less weight gain than the other atypical antipsychotics."
A nurse uses healing touch to care for patients on a hospital ward. For which patients would this practice be most appropriate? (
A patient with a surgical wound • A patient who has unrelenting pain • A patient who is being prepared for a surgical procedure • A patient whose energy field is unbalanced
After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. The client is showing signs of which of the following extrapyramidal adverse reactions?
Akathisia.
The client is to undergo a series of diagnostic tests to determine if the client's cognitive impairment is treatable. Which of the following states can lead to nonreversible cognitive impairment?
Alzheimer's disease.
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
An injection of tetanus toxoid. Tetanus toxoid is indicated, since there has been no booster in the last 5 years. With a human bite there is a risk of severe infection;
The nurse is teaching a patient how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include?
Buy herbs and supplements that are standardized. • Give the product adequate time to work. • Be knowledgeable about the product and its therapeutic actions. Correct
Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement?
Continue previous contraceptive use even if you're experiencing amenorrhea.
A nursing student asks her instructor to discuss chiropractics and how they are useful as an alternative to medicine. The nursing instructor bases her response on her knowledge that chiropractics are useful to the following. Select all that apply
Correcting alignment problems • Alleviating pain • Improving function • Supporting the body's natural ability to heal itself
The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate?
Delusion of persecution.
A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which of the following infection control practices does the nurse consider most important for this client?
Diligent adherence to aseptic technique
A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in her part-time employment, states that she is very concerned about her 20-pound (9.1-kg) weight gain since she started taking the medication 6 months ago. The nurse should:
Discuss nutrition, daily diet, and exercise with the client.
Which is the most important role of the nurse in using complementary and alternative therapies?
Educating the public about safety and effectiveness
The nurse is slightly overweight and decides to take a holistic approach to losing weight. The nurse does which of the following? Select all that apply.
Eliminates cola drinks • Decreases refined sugar • Avoids foods with preservatives • Adopts a vegatarian diet
One day after a client with schizophrenia began treatment with haloperidol, a nurse notices that he is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?
Evaluate the client for adverse reactions to haloperidol.
When caring for a client receiving haloperidol, the nurse should assess for which of the following?
Extrapyramidal symptoms
A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?
Granulocytopenia
A dystonic reaction can be caused by which medication?
Haloperidol
The physician recommends that you have your daughter vaccinated with HPV vaccine. What is this vaccine for?
Help prevent cervical cancer
A health care provider has been exposed to hepatitis B through a needlestick. Which of the following drugs should the nurse anticipate administering as postexposure prophylaxis?
Hepatitis B immune globulin.
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
IgE
The nurse is conducting a mental status examination on a client with a cognitive disorder. Which of the following findings does the nurse judge to be an impairment in abstract thinking?
Inability to find a similarity between a bird and a butterfly.
When preparing a presentation for a group of senior citizens, which vaccine would the nurse recommend that this age group receive annually?
Influenza
A client with a history of type 1 diabetes mellitus and chronic obstructive pulmonary disease should have which of the following immunizations?
Influenza.
A nurse is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?
It's characterized by an acute onset and lasts hours to a number of days.
Which group of characteristics should a nurse expect to see in the client with schizophrenia?
Loose associations, grandiose delusions, and auditory hallucinations
The nurse at the mental health center has been asked to develop a staff in-service program about adult clients with schizophrenia. Which of the following characteristics would the nurse most likely find common to this group of clients?
Medication noncompliance is the primary cause of relapse.
he nurse is teaching a class on methods of relaxation to be used for stress management. Which methods should the nurse teach the participants? Select all that apply.
Meditation • Biofeedback • Imagery • Focused breathing
A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan?
Meeting all of the client's physical needs
A client asks the nurse about taking herbal medications. Which of these is the nurse's best response regarding safety of the herbal medications?
Name brand products with herbal medications usually are of higher quality.?
A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms?
Negative symptoms
A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest?
Neuroleptic malignant syndrome
A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect?
Neuroleptic malignant syndrome
The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take?
Obtain an order for the client to have a white blood cell count drawn.
Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?
Obtain influenza and pneumococcal vaccines.
A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." The nurse should first:
Obtain information about the client's medication compliance.
A client taking risperidone 2 mg orally twice a day informs the nurse that she will be getting married in 3 months to another client she met at the outpatient clinic. During the client interview, the nurse should ask the client further about:
Plans to become pregnant.
A nurse wishing to learn about techniques of therapeutic touch is referred to a trained practitioner to observe the technique. While the practitioner is in the centering stage, which activity would the nurse most likely observe?
Practitioner brings attention inward to a peaceful state of consciousness
A paranoid client is having a delusion. While the client is having a delusion, the nurse should:
Present reality when the client asks about the delusion.
A nurse is immunizing children against measles. This is an example of what level of preventive care?
Primary
A nurse is teaching a client about holistic approaches to food choices. Which of the following would the nurse recommend?
Reduce refined sugar intake.
A nurse is preparing to teach a client about relaxation. Which of these statements would be accurate regarding the use of relaxation?
Relaxation will improve the client?s feeling of well-being.
A nurse is planning care for a client with a diagnosis of schizophrenia who has been admitted to the psychiatric unit. Which nursing diagnosis should receive the highest priority?
Risk for other-directed violence
A client has a history of schizophrenia. Because he has a history of noncompliance with antipsychotic therapy, he will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?
Sitting up for a few minutes before standing to minimize orthostatic hypotension
A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My mom and I are so excited that I am pregnant. She is willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation?
Symptom management will be difficult in early pregnancy without medications.
A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?
Tardive dyskinesia
The nurse hands the medication cup to a client who is psychotic and exhibiting concrete thinking, and tells the client to take his medicine. The client takes the cup, holds it in his hand, and stares at it. What should the nurse do next?
Tell the client to put the medicine in his mouth and swallow it with some water.
For the client with catatonic behaviors, which outcome would indicate a medication has been most effective in improving long-term behavior?
The client initiates simple activities without directions.
A nurse is teaching a psychiatric client about his ordered drugs, chlorpromazine and benztropine. What evaluation would indicate a therapeutic response to these drugs?
The client is experiencing less psychosis and a decrease in extrapyramidal symptoms
Which of these assessment findings indicate a positive outcome for a client after acupuncture?
The client reports a reduction in pain level to 3 out of 10.
A client asks about whether to consult a naturopathic physician for treatment. Which client factor would the nurse consider in determining the client would benefit from this consult?
The client states ?I spend a lot of time watching television.? Explanation: With naturopathy, observation of natural laws helps to maintain health in a complex society. If people ignore these laws, illness can result. This includes leading a sedentary lifestyle, eating processed and overcooked foods, not getting adequate rest, and maintaining a negative attitude. The client who would benefit most from health promotion is the one who ?spends a lot of time watching television.?
The nurse is providing client education about the use of herbal medicines. Which information are accurate? Select all that apply.
They contain certain amounts of active ingredients. • They can be toxic in high doses. • They take longer to produce a therapeutic effect.
Which effects do most antipsychotic medications exert on the central nervous system (CNS)?
They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.
The client with Alzheimer's disease has been prescribed donepezil, 5 mg at bedtime. Which instructions should the nurse give to the client's daughter?
To avoid suddenly stopping the medication
A client has been receiving chlorpromazine, an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?
Tremors, shuffling gait, and masklike face
A client with schizophrenia believes his room is bugged by the Central Intelligence Agency (Canadian Security Intelligence Service) and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and has not been employed in the past 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?
Trust versus mistrust
When providing holistic care to a client, the nurse recognizes that which of the following is necessary?
Understand and respect each person's definition of health. • Understand and respect each person's responses to illness.
Which of the following is the most effective strategy to prevent hepatitis B infection?
Vaccine
A client with schizophrenia is having an acute exacerbation of symptoms. The client states, "Black cats and black hats. Where does the time go?" Which of the following would be most important for the nurse to say?
What's the connection between cats, hats, and time?"
A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride p.o qid. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take?
Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs.
A nurse is assessing a client who is receiving clozapine. The nurse reviews the accompanying chart. What should the nurse do next?
Withhold the clozapine and notify the physician.
A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:
a calming effect from which the client is easily aroused.
A client with schizophrenia hears a voice telling him that he is evil and must die. The nurse understands that this client is experiencing:
a hallucination.
One of the advantages of the antipsychotic medication APO-risperidone is
a lower incidence of extrapyramidal effects
A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action should be to:
administer an as-needed dose of benztropine I.M. as ordered.
An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations?
alcohol withdrawal
A nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is:
benztropine.
Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by
blocking cholinergic activity in the central nervous system (CNS)
The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting:
clang association.
A client with active psychosis is admitted to the psychiatric unit. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:
disturbances in affect, perception, and thought content and form.
One of the causes of schizophrenia involves an overstimulation of:
dopamine.
When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which intervention should the nurse employ as the first step?
eliminating distracting stimuli such as turning off the television
A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as being consistent with which factor?
expected adverse effect of clozapine
Positive symptoms of schizophrenia include:
hallucinations, delusions, and disorganized thinking.
A nurse is caring for a client who experiences false sensory perceptions that have no basis in reality. These perceptions are known as:
hallucinations.
During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The nurse interprets these findings to indicate that the client needs which intervention?
immediate medical evaluation
A client with early dementia exhibits disturbances in mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which other area?
judgment
A nurse is aware that antipsychotic medications may cause:
lower seizure threshold
A man is brought to the hospital by his wife, who states that he has refused all meals for the past week and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. A physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by:
preoccupation with persecutory delusions, anxiety, anger, and potential for violence
An agitated and incoherent client comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that this client was hospitalized for schizophrenia from ages 20 to 21. The physician orders haloperidol, 5 mg I.M. The nurse understands that this drug is used in this client to treat:
psychosis
A client's medication order reads, "Thioridazine 200 mg P.O. q.i.d. and 100 mg P.O. p.r.n." A nurse should:
question the physician about the order.
A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a:
somatic delusion.
When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands:
the client must take benztropine as ordered to prevent a return of symptoms
The husband of a client who was diagnosed 6 years ago with Alzheimer's disease approaches the nurse and says, "I am so excited that my wife is starting to use donepezil for her illness." The nurse should tell the husband:
the medication is effective mostly in the early stages of the illness.
When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, "I am being followed; it is not safe. They are monitoring my every move." In which area of the mental status examination should the nurse document this information?
thought content
Propranolol is used in the mental health setting to:
treat antipsychotic-induced akathisia and anxiety.
A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains his pulse and blood pressure readings, and the nurse must reposition his arm. This client is exhibiting:
waxy flexibility.
During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:
waxy flexibility.
Which action by the nurse is likely to increase the anxiety and suspiciousness of a client who is delusional?
whispering with others where the client can observe
