Saunders-MH

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1.Monitor closely for harm to self or others. 2.Assist in completing an application for admission. 3.Supply the client with written information about her or his mental health problem. 4.Provide an opportunity for the family to discuss why they felt the admission was needed.

1.Monitor closely for harm to self or others.

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? 1. Signs of depression 2.Reactions to a devastating event 3.Evidence that the client is a high suicide risk 4.Indicative of the need for hospital admission

2.Reactions to a devastating event

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?"

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4. "You sound very upset. Are you thinking of hurting yourself?"

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2.A crisis state indicates that the client has an emotional illness. 3.Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4.A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4.A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1. Dental decay 2.Moist, oily skin 3.Loss of tooth enamel 4.Electrolyte imbalances 5.Body weight well below ideal range

1. Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 4.Provide stimulation in the environment. 5.Provide reality orientation as appropriate. 6.Maintain NPO (nothing by mouth) status

1. Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 5.Provide reality orientation as appropriate.

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2.Provide the clients on the unit with a sense of comfort and safety. 3.Assist the staff in caring for the client in a controlled environment. 4.Offer the client a less stimulating area in which to calm down and gain control.

1. Provide safety for the client and other clients on the unit.

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs

4. Helping the client to examine dysfunctional thoughts and beliefs

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."

1. "I no longer feel that I deserve the beatings my husband inflicts on me."

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1. Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive

1. Avoidant

A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2.Call security to block all exit areas. 3.Restrain the client until the primary health care provider (PHCP) can be reached. 4.Tell the client that the client cannot return to this hospital again if the client leaves now.

1. Call the nursing supervisor.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2.Ensure that the client knows that they are not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1. Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2. Use an indirect light source and turn off the television.

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2."What do you find difficult about this situation?" 3."This is not the best time to make that decision." 4."I agree with you. You should get out of this situation."

2."What do you find difficult about this situation?"

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2.A client undergoing diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtime

2.A client undergoing diagnostic tests

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations

2.Identifying anxiety-producing situations

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? 1. Psychosis 2.Repression 3.Conversion disorder 4.Dissociative disorder

3.Conversion disorder

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2.Tell the client that the behavior is inappropriate. 3.Escort the client to their room, with the assistance of other staff. 4.Tell the client that their telephone privileges are revoked for 24 hours.

3.Escort the client to their room, with the assistance of other staff.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? 1. Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed

3.Increasing the level of suicide precautions

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2.Leave the client alone so as to minimize external stimuli. 3.Sit beside the client in silence with simple open-ended questions. 4.Take the client into the dayroom with other clients to provide stimulation.

3.Sit beside the client in silence with simple open-ended questions.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute.

4. Thank the client for the input, but inform the client that others now need a chance to contribute.

The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2.Stupor, lethargy, muscular rigidity 3.Hypotension, coarse hand tremors, lethargy 4.Hypertension, changes in level of consciousness, hallucinations

4.Hypertension, changes in level of consciousness, hallucinations

The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2.Exploring the client's potential for self-harm 3.Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4.Inquiring about and examining the client's feelings for any that may block adaptive coping

4.Inquiring about and examining the client's feelings for any that may block adaptive coping

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2.Active listening 3.Asking the client "Why?" 4.Maintaining neutral responses 5.Providing acknowledgment and feedback 6.Giving advice and approval or disapproval

1. Restating 2.Active listening 4.Maintaining neutral responses 5.Providing acknowledgment and feedback

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2."You will need to be placed in seclusion." 3."You seem restless; tell me what is happening." 4."You will need to be restrained if you do not change your behavior."

3."You seem restless; tell me what is happening."

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times. 2.Removing the client's clothing and placing the client in a hospital gown. 3.Assigning to the client a staff member who will remain with the client at all times. 4.Admitting the client to a seclusion room where all potentially dangerous articles are removed.

3.Assigning to the client a staff member who will remain with the client at all times.

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2.Substituting other activities for gambling 3.Stating that the gambling will be stopped 4.Discontinuing relationships with people who gamble

1. Admitting to having a problem

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? 1. Information regarding shelters 2.Instructions regarding calling the police 3.Instructions regarding self-defense classes 4.Explaining the importance of leaving the violent situation

1. Information regarding shelters

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? 1. Milieu therapy 2.Interpersonal therapy 3.Behavior modification 4.Support group therapy

1. Milieu therapy

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that they will not be able to attend any future group sessions

1. Setting limits on the client's behavior

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2.The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3.The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4.The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2.Evidence of the client's disturbed body image 3.Regression as the client is moving toward the community 4.Indicative of the client's ambivalence about hospital discharge

2.Evidence of the client's disturbed body image

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1. Initiate confinement measures. 2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. 5.Allow the client to take control of the situation.

2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2.Ask the client about the amount of drug use and its effect. 3.Ask the client how long he thought that he could take drugs without someone finding out. 4.Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2.Ask the client about the amount of drug use and its effect.

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? 1. Increase socialization of the client with peers. 2.Avoid using a whisper voice in front of the client. 3.Begin to educate the client about social supports in the community. 4.Have the client sign a release of information to appropriate parties for assessment purposes.

2.Avoid using a whisper voice in front of the client.

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2.Interrupt the client and offer to take her for a walk. 3.Allow the client to complete her exercise program. 4.Tell the client that she is not allowed to exercise rigorously.

2.Interrupt the client and offer to take her for a walk

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2."Who is available to help you?" 3."What leads you to seek help now?" 4."What do you usually do to feel better?"

3."What leads you to seek help now?"

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities until the client asks to participate in milieu 4.A structured program of activities in which the client can participate

4.A structured program of activities in which the client can participate

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

2.The death of a loved one

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2.Writing 3.Board games 4.Group exercise

2.Writing

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2."It will take some time to get over these feelings about your rape." 3."Tell me more about the incident that causes you to feel like the rape just occurred." 4."What do you think that you can do to alleviate some of your fears about being raped again?"

3."Tell me more about the incident that causes you to feel like the rape just occurred."

The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1. "My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."When I have command hallucinations, I'll call a friend for help." 4."I need to get enough sleep and eat well to help prevent feeling anxious."

3."When I have command hallucinations, I'll call a friend for help." Contact health care provider instead