Psych 2

A nurse on an acute mental health unit is caring for a client who has depression. Which of the following is the highest priority nursing intervention?

Monitor for risk of self-harm.

A nurse is caring for a client who has a serum lithium levle of 2.0 mEq/L. Which of the following is the priority action for the nurse to take?

Notify the primary provider of this toxic blood level

A nurse on a mental health unit is caring for clients who have the following depressive disorders. The nurse should identify which of the following diagnoses as presenting the greatest risk for suicide?

Recurrent brief depression

A nurse is teaching a client who has depression aout a new presription for fluoxetine (Prozac). Which of the following statements by the client indicates unerstanding of the teaching?

"I should watch my diet to prevent an expected weight gain."

A nurse is caring for a client who is depressed and refuses to participate in group therapy, or perform activities of daily living. Which of the following nursing statements by the nurse is appropriate?

"I will assist you in getting out of bed and getting dressed."

A client calls the crisis hotline and tells the nurse who answers the phone, "I just took an entire bottle of amitriptyline (Elavil)." Which of the following statements by the nurse is appropriate?

"I'm glad you called, and I want to send an ambulance to help you."

A nurse is caring for a client who is diagnosed with depression. The client's spouse asks the nurse about possible side effects of electroconvulsive therapy (ECT). After explaining that ECT will not cause brain damage, what additional information should the nurse offer?

"The main side effects are temporary, and may include mild confusion, a slight headache, and short-term memory problems."

A nurse is teaching the family of a client who has a diagnosis of dementia. Which of the following statements is appropriate to include in the teaching?

"The signs of dementia are progressive and irreversible."

A nurse is providing medication teaching for a client who has a new prescription for phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI). Which of the following should the nurse include in the teaching?

"You should change positions slowly while taking this medication."

A nurse is caring for a client who has bipolar disorder and is hospitalized for a severe depressive episode. The client has been taking citalopram (Celexa) for 2 weeks and reports sleeping better and having an improved appetite, but the client still feels hopeless. Which of the following is an appropriate nursing action?

Explain that antidepressants often take several weeks to be fully effective.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following behaviors that may cause lithium toxicity?

Fasting

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following should the nurse include? (Select all that apply.)

Grooming Long-term memory Affect

A client who is newly diagnosed with Alzheimer's disease asks how the symptoms will progress. How should the nurse respond? Place in order.

Inability to find commonly used items Inability to perform common tasks Difficulty with talking or reading Inability to remember family members Difficulty remembering how to swallow

A nurse is planning care for a client following a suicide attempt. Which of the following interventions is appropriate when implementing suicide precautions?

Inspect the client's personal belongings.

A nurse is planning care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care?

Limit the client's choices for daily activities.

A nurse is admitting a client with a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

Mental status questionnaire

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following is an appropriate nursing intervention for helping this client at this time?

Sit with the client during meals and snacks.

A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic in the client's plan of care?

Spending time with the client.

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors? (Select all that apply.)

Substance abuse Age greater than 45 years old Schizophrenia

A nurse on an inpatient mental health unit is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority?

Suicide risk

A nurse is caring for a client who has bipolar disorder. Which of the following should be recognized as manic behavior? (Select all that apply.)

Talking in rapid, continuous speech Interacting with others in a flirtatious way Spending large sums of money

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

Walking with the nurse in the courtyard

A nurse is caring for a client who has been prescribed lithium carbonate (Eskalith) for the treatment of bipolar disorder. Which of the following should the nurse include in her teaching with the client and family regarding this medication?

You will need to stop taking this medication if you experience diarrhea, vomiting, and/or excessive sweating.

A nurse is caring for a client who is a resident in a facility designed for the care of clients with Alzhemier disease. The client has been oriented to name and place and is usually cooperative and able to perform activities of daily living (ADL) with minimal supervision. When the client refuses to take medications, the nurse should:

ask the client to express the reasons for refusing the morning medications and document the event.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize this when the client:

makes up stories when unable to remember actual events.