VATI Mental Health
A nurse in an emergency department is preparing to discharge a client who has severe HTN and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?
A residential rehabilitation program. -These programs have a 24hr medical staff and provides specialized care for clients who have comorbid conditions.
A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect?
Dental caries -Have dental caries and tooth erosion due to excessive exposure to stomach acid from frequent vomiting.
A nurse is teaching a client who has alcohol use disorder about medications that can be used to treat manifestations of withdrawal. The nurse should include information about which of the following medications?
Lorazepam -Lorazepam is a benzodiazepine that helps to alleviate the clients craving for alcohol.
A nurse is assessing a client whose child died 1 year ago. Which of the following findings indicates the client might be experiencing major depressive disorder rather than an expected grief response?
Loss of self-esteem due to feelings of worthlessness. -Expected grief responses include an intact self-esteem, a focus on the deceased, and feelings of sadness that decrease over time.
A charge nurse is discussing elder abuse with a newly licensed nurse. Which of the following responses by the newly licensed nurse demonstrates an understanding of elder abuse?
Older adults who are dependent on a caregiver might be at an increased risk for abuse. -Caregiver strain can increase the risk for elder abuse. An older adult who is dependent on others for care due to poor physical health, or a chronic disease such as Alzheimer's disease, is at an increased risk for abuse.
A nurse is preparing to administer methylphenidate 30mg PO to a school age child who has ADHD. Available is methylphenidate oral solution 10mg/5mL. How many mL should the nurse administer?
15 mL
A nurse is assessing a group of clients in a community health clinic. In which of the follwoing situations should the nurse identify a requirement to report child or vulnerable adult maltreatment to an appropriate agency? SATA
A 7-year-old child has a variety of old and new bruises on his back and posterior thighs. A 2-year-old child has a spiral fracture of his arm, which the parent states happened when he fell from a swing. An 80-year-old client who has dementia and lives in a group home has bruises in the perineal area. -A variety of bruises in different stages of healing and in an area unlikely to be bruised on a school aged child is suspicious and must be reported to the appropriate agency. -Explanations regarding injuries that do not match the presentation of an injury are suspicious and must be reported to the appropriate agency. A spiral fracture is most likely to be caused by an adult twisting a child's limb with their hands, rather than by a fall from a swing. -The nurse must report suspicious assessment data in vulnerable older adults as well as children. Perineal bruising is not expected in an older adult who has dementia and should be reported.
A charge nurse is teaching a group of newly licensed nurses about different types of therapeutic support groups. Which of the following statements should the nurse make?
A bereavement support group helps clients who are experiencing loss. -Bereavement support group teaches participants how to deal with significant emotional stressors, such as loss and grief. One of the most important aspects of the group is the commonality of the shared experience between members. This commonality provides support and comfort to participants.
A charge nurse is conducting an in-service for a group of newly licensed nurses about risk factors for child maltreatment. Which of the following examples should the nurse include in the teaching?
A child who was born with cleft lip and palate. -Having a congenital abnormality, such as cleft lip and palate, increases a child's risk for bring maltreated. The nurse should also teach the group of nurses that children who are younger than 3 years of age and children from an unwanted pregnancy are at risk for maltreatment.
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis?
A client who recently lost their home in a fire. -An adventitious crisis is caused by an unplanned event, such as a fire, earthquake, riot, plan crash, or violent crime.
A nurse is caring for a client whose partner recently died. Which of the following actions should the nurse take?
Allow the client to experience and express grief in personally unique ways. -Encourage the client to verbalize their feelings and express them in ways that assist them in coping with the loss.
A nurse is discussing therapeutic communication with a group of newly licensed nurses. Which of the following phrases should the nurse use as an example of offering general leads?
And after that? -Give this example as the technique of offering a general lead. This therapeutic communication technique offers the client encouragement to continue the conversation with the nurse.
A nurse is creating a plan of care for a client who has posttraumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan?
Assign the same staff to care for the client. -Client who has PTSD can be suspicious of others in their environment and assigning the same staff will facilitate a trusting relationship.
A home health nurse is caring for a new client who has hoarding disorder that involves food. Which of the following actions should the nurse take first?
Assist the client with completing the Hoarding Scale Self Report. -Asking the client to complete the report provides data about the severity of the clients hoarding behavior.
A nurse is caring for a client who has bipolar disorder and is taking carbamazepine. The nurse should monitor the client for which of the following adverse effects?
Ataxia -CNS adverse effects are common during the first few weeks when beginning to take carbamazepine. These adverse effects include vertigo, ataxia, and downiness.
A nurse is providing dietary teaching to a client who has a prescription for tranylcypromine. The nurse should instruct the client to avoid which of the following foods while taking this medication?
Avocados -High tyramine content, which promotes the release of norepinephrine from sympathetic neurons. Consuming avocados while taking tranylcypromine can result in a hypertensive crisis due to massive vasoconstriction and excessive stimulation of the heart. Tyramine levels are highest in very ripe avocados.
A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?
Avoids self responsibility. -Has a great need to be taken care of, which leads to fears of separation, difficulty making decisions, and avoidance of taking responsibility for most aspects of life.
A nurse is discussing stress management techniques with a client who has an anxiety disorder. Which of the following information should the nurse include?
Biofeedback teaches you to control physical reactions to stress, such as your heart rate. -Biofeedback uses sensitive instrument that detect changes in muscle activity, heart rate, respiratory rate, and skin temperature. Stress causes an increase in theses autonomic responses. Allows clients to learn how to gain voluntary control over theses responses, thereby decreasing feelings of stress.
A nurse is planning care to assist a client with smoking cessation. Which of the following medications should the nurse expect the provider to prescribe?
Bupropion -An atypical antidepressant, to a client undergoing nicotine withdrawal. Bupropion reduces the addictive action of nicotine and can minimize the manifestations of withdrawal.
A nurse in a mental health clinic receives a phone call from a client who has a mental health disorder and lives at home. The client reports they cannot afford to refill their prescription for an antipsychotic medication and requests assistance. Which of the following members of the client's health care team should the nurse notify?
Case Manager -A case manager or social worker coordinates care for a client who has a mental health disorder, including sources of financial aid. They can provide care in the client's home, school, or place of employment. This care can include medication monitoring and guidance with community services.
A nurse in an emergency department is assessing an older adult client who was brought in by a family member. The family member reports that the client has had a change in behavior over the past 2 days. The nurse should identify that which of the following findings is an indication that the client has delirium? SATA
Change in LOC Decreased attention span Hallucinations -Change in LOC is an indication that the client is experiencing delirium, which the nurse should observe as a decreased awareness of surroundings. -Delirium usually shows a disturbance in ability to focus and maintain attention as well as memory impairment and poor judgement. -Hallucinations can indicate that the client is experiencing delirium. Hallucinations are false sensory perceptions that can increase the clients fear and anxiety.
A nurse is caring for a client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?
Check the client's physical needs every 15mins while in seclusion. -Assess and document the client's physical, comfort, and safety needs every 15mins. Assessing and documenting at such frequent intervals minimizes the risk of injury to the client and provides a legal record of the care the client is receiving.
A nurse is caring for a client whose partner died 3 years ago. The client has withdrawn socially and has not participated in regular activities since the funeral. The nurse should identify that the client is experiencing which of the following types of grief?
Chronic grief -Occurs when there is a prolonged emotional instability, a withdrawal from usual tasks or activities, and lack of progression to successful coping with loss.
A nurse is assessing a client who is taking fluphenazine and received a dose of benztropine to treat an acute dystonic reaction. Which of the following findings indicates that the benztropine is effective?
Decrease in facial muscle spasms. -Benztropine is an antiparkinsonian medication used to treat acute dystonic reactions, which can be an adverse effect of antipsychotic medications such as fluphenazine. An acute dystonic reaction causes painful contractions of the face, tongue, jaw, neck, and back. Benztropine reduces muscle spasms and rigidity.
A nurse in an acute mental health facility is assessing a newly admitted client who has schizophrenia. Which of the following findings should the nurse identify as the priority to assess further?
Command hallucinations -The greatest risk to this client is injury to self or others due to command hallucinations. Command hallucinations occur when the client hears inner voices that tell them to take an action, such as self harm or harm to others. The nurse should ask the client what the voices are telling them to do.
A nurse is providing discharge teaching to a family member of a client who has moderate Alzheimer's disease. Which of the following information should the nurse include?
Consider using respite care services. -These services allow time to rest and strengthen the ability to be a caregiver. Long term illness affects the caregiver's mental, physical, emotional, and spiritual health.
A nurse in a community program for clients who experience partner violence is planning secondary prevention strategies. Which of the following interventions should the nurse plan to include?
Coordinating community resources for a hospitalized client. -Secondary prevention strategies include intervening for a client who is currently experiencing partner violence, counseling the client, and arranging a move to a safe house.
A nurse is creating a plan of care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse plan to include?
Decrease the volume of the television in the dayroom. -The nurse should also dim bright lights and avoid placing the client in a group of people.
A nurse is planning care for a client who is withdrawing from alcohol. Which of the following medications should the nurse plan to administer during the acute phase of alcohol withdrawal?
Diazepam -Benzodiazepine, to client during acute alcohol withdrawal to raise the seizure threshold and prevent seizures, decrease agitation, stabilized vital signs, decrease the intensity of withdrawal manifestations, and prevent delirium tremens.
A hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatment. One of the adult children is angry with the provider and blames the provider for their father's death. Which of the following defense mechanisms is the family member using?
Displacement -When this family member uses displacement, they are transferring their feelings of anger to the provider so they do not have to cope with their own feelings of sadness and loss.
A nurse is caring for a client who is experiencing a manic episode. Which of the following actions should the nurse take first?
Encourage the client to rest each hour. -The greatest risk to this client is injury from exhaustion due to the manic phase, therefore, the priority action the nurse should take is to encourage the client to rest for 3-5mins every hour.
A nurse is assisting in obtaining informed consent from a client who is scheduled for Vagus nerve stimulation. Which of the following actions should the nurse take to act as a client advocate?
Ensure the client signs the form voluntarily. -The nurse acts a client advocate by ensuring that the client gives consent voluntarily, appears competent to provide consent, and has received information about the purpose, alternatives, risks, and benefits of the procedure.
A nurse is reviewing a laboratory report of a client who is taking olanzapine. Which of the following laboratory values should the nurse report to the provider?
Fasting blood glucose 140 mg/dL. -Olanzapine is an atypical antipsychotic medication prescribed for the treatment of schizophrenia. An adverse effect is hyperglycemia. The expected reference range for fasting glucose is 74-106 mg/dL.
A nurse is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?
Fear of being abandoned by others. -Other manifestations include submissiveness and a desire to be cared for.
A nurse in an outpatient mental health facility is assessing a family unit that consists of grandparents, parents, and several children. Which of the following tools should the nurse plan to use to assist in assessing this group of clients?
Genogram -Assess the current and past functioning of a family unit of several generations. The nurse should collect information about where the family lives, educational level of the members, and occupations, as well as information about medical, emotional, and behavioral status.
A nurse is assessing a client who has schizophrenia. The nurse observes lip smacking, jaw clenching, and repeated tongue protrusions. Which of the following prescribed medications should the nurse identify as the potential cause of these findings?
Haloperidol -The nurse should identify that these findings indicate tardive dyskinesia, which is a potential adverse effect of antipsychotic medications such as haloperidol. Tardive dyskinesia usually persists even after discontinuation of the medication.
A nurse is caring for a client following a fire that destroyed her home and killed one of her children. The client is crying and does not make eye contact with the nurse. Which of the following questions should the nurse ask first?
Have you thought of harming yourself? -The greatest risk to this client is self harm due to the loss of her child and home, therefore, the first question the nurse should ask a client who is having a personal crisis is to determine if the client has suicidal ideation. If so, the nurse should take action to protect the client from self harm.
A nurse is assessing a client for a substance use disorder. The client exhibits yawning, pupillary dilation, rhinorrhea, and reports muscle cramps. The nurse should suspect that the client is withdrawing from which of the following substances?
Heroin -Manifestations of opioid withdrawal can include severe muscle cramps, yawning, rhinorrhea, and pupillary dilation. A client who is withdrawing from heroin can start to experience manifestations within 6-8hrs after the last dose following a period of at least 1 week of use.
A nurse is preparing to administer escitalopram to a client who reports taking St. John's wort 1hr ago. Which of the following actions should the nurse take?
Hold the dose of escitalopram and consult the provider. - St. John's wort can increase the risk of serotonin syndrome when combined with escitalopram, a selective serotonin reuptake inhibitor (SSRI).
A nurse is caring for a client who has a depressive disorder and recently started taking a selective serotonin reuptake inhibitor. For which of the following findings should the nurse monitor to identify serotonin syndrome?
Hyperpyrexia -The nurse should initiate the use of cooling blankets or other means to lower body temperature.
A nurse is caring for an adult client who was involuntarily admitted following a suicide attempt. The nurse receives a call from the client's spouse asking for a status report. Which of the following responses should the nurse make?
I cannot discuss your spouse's health information with you without his consent. -HIPAA protects a client privacy regardless of admission status. The client can approve individuals with whom the nurse can share information. Releasing protected health information without permission from the client is an invasion of privacy and a HIPAA violation.
A nurse in an acute care facility is providing teaching for the adult child of an older adult client who is admitted with a urinary tract infection and delirium. The client has been living independently at home. Which of the following statements by the adult child demonstrates the teaching has been effective?
I expect that my father will no longer be confused when he is discharged.
A nurse is caring for a client who has schizophrenia and is experiencing visual hallucinations. The client states, "That man on the ceiling is ridiculing me." Which of the following responses should the nurse make?
I'm sorry but I do not see anything on the ceiling. -Use therapeutic communication to address the client's hallucinations and delusions. The nurse should offer their own perception of what the client is seeing or hearing without negating the client's experience.
A nurse on a mental health unit is conducting a one-on-one session with a client who suddenly becomes silent. Which of the following responses should the nurse make?
I've noticed you have become quiets. Please share with me what you are thinking. -Making observation about the clients feelings, which encourages the client to discuss their thoughts, and facilitates further communication with the nurse.
A nurse is caring for a client who has schizophrenia and is experiencing frequent delusions. Which of the following strategies should the nurse use when caring for the client?
Identify the client's feelings underlying the delusions. -The nurse should focus on the client's underlying feelings, rather than on the illogical aspects of the delusion. The nurse should encourage the client to talk about their fears and anxieties that relate to the delusion without any assumptions and statements about the delusion being real or false.
A charge nurse on a mental health unit is discussing legal issues with a newly licensed nurse. Which of the following statements should the charge nurse include?
If a client threatens to seriously harm someone, the provider should notify that person of the threat. -Nurses should report a client's threat to the provider, and the provider has a legal obligation to notify third parties when a client threatens serious harm. If the risk for violence exists, the provider should notify the person, the person's family, or local law enforcement.
A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first?
Inform the client that this admission is confidential. -According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse client relationship. This action establishes trust between the client and the nurse, which in turn decreases the client's anxiety level.
A nurse is developing a plan of care for an adolescent client who has conduct disorder. Which of the following interventions should the nurse include in the plan?
Initiate a behavioral contract with the client. -A client who has conduct disorder can demonstrate patterns of behavior that are aggressive, disrespectful of others rights, and can lead to injury of others. A behavioral contract helps to develop trust between the client and the nurse and emphasizes the client's responsibility to commit to work on changes in behavior.
A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. The nurse should identify that which of the following outcomes is an advantage of buspirone?
It does not cause physical dependence. -Unlike other antianxiety agents, buspirone is not a CNS depressant. It does not cause physical or psychological dependence and does not produce tolerance. Buspirone might also be prescribed for clients who have other types of anxiety disorders, such as obsessive-compulsive disorder.
A nurse is caring for a client who appears extremely agitated and believes that pacing the floor a specific number of times is necessary or "something terrible" will happen. Which of the following responses should the nurse make?
It must be hard for you to have to pace the floor. Let's talk about your feelings. -Making observations and offering a general lead, which allows clients to notice their behavior and discuss their feelings with the nurse. The client is displaying obsessive-compulsive behavior. Clients who have this disorder are aware that their behavior is excessive but are unable to stop the behavior.
A home health nurse is providing education for the family of a client who has dementia. Which of the following interventions should the nurse recommend?
Limit fluid intake after the client's evening meal. -Educate the family to limit the client's fluid intake after the evening meal around 1800. The family should offer the client fluids every 2hrs during the day to prevent dehydration, but to minimize nighttime incontinence, they should limit or restrict fluid intake after 1800.
A nurse is providing teaching to a client who has bipolar disorder and has been taking lithium for 4 months. The client's serum lithium levels are within the therapeutic range. Which of the following instructions should the nurse include to promote the maintenance of the therapeutic lithium level?
Limit outdoor exercise during hot weather. -Spending time outdoors during hot weather, especially if exercising, promoting dehydration and sodium loss through diuresis, which can increase lithium levels. Whenever the client exercises, develops diarrhea, vomits, or has any circumstance that can cause dehydration, fluids and electrolytes must be replaced promptly.
A nurse is providing morning care for a client who has Alzheimer's disease and has frequent outbursts of aggression. Which of the following actions should the nurse take?
Limit the client's choices. -Asking the client to choose between three or four options can lead to anxiety and agitation; Therefore, if the client is capable of making choices, the nurse should limit choices to no more than two at a time, such as making decisions about eating and getting dressed.
A nurse in an acute care mental health facility is preparing a client for discharge. Which of the following tasks should the nurse include in the termination phase of the nurse-client relationship?
Make appropriate referrals. -During the termination phase of the nurse-client relationship, the nurse should make referrals to appropriate agencies for the client to contact if they need help in the future. It is also necessary for the nurse to collaborate with the client's case manager prior to making referrals to ensure continuity of care for the client.
A nurse is providing teaching about levels of anxiety to a group of clients who have anxiety disorders. Which of the following statements should the nurse include?
Moderate anxiety causes HA and insomnia. -Somatic manifestations begin during moderate anxiety. Clients can experience urinary frequency, muscle tension, HA and insomnia. If anxiety progresses to severe levels, somatic manifestations worsen and can include chest pain, dizziness, and diaphoresis.
A nurse is leading a medication education group for several clients. A client who is sometimes violent becomes angry and begins yelling at others in the group. Which of the following actions should the nurse take? SATA
Move others away from the client. Offer the client a PRN dose of lorazepam. Ask the client open ended questions about the behavior. -A large personal space should be maintained around the client who is angry. If the client's behavior continues to escalate, the nurse should move others away from the client for their safety. -Antianxiety medication can be used in conjunction with de-escalation techniques to prevent a violent episode. -Communication technique is nonthreatening and encourages the client to express their feelings.
A nurse is counseling a client who has alcohol use disorder and has chosen to enter a treatment program. The clients states, "I need to find a program that won't interfere with my job." The nurse should identify which of the following community resources as being the least restrictive?
Outpatient treatment program. -When using the least restrictive framework, the nurse should identify that an outpatient treatment program provides the least restrictive alcohol use disorder treatment. This form of treatment is nonresidential and includes treatment groups an individual therapy of no more than 5hrs per week.
A nurse is discussing resources with the case manager of a client who has schizophrenia and heart failure. Which of the following resources should the nurse recommend to address the client's behavioral health and medical needs?
Patient-centered medical home (PCMH) -Provides behavioral health and medical services. It offers extended hours of service 7 days a week with comprehensive patient-centered care. Clients participating in the patient-centered medical home receive comprehensive care as well as supportive community and social services. Services such as email and phone support to clients are a part of the patient-centered medical home.
A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan?
Provide the client with plastic eating utensils. -The client can use glass dishes and metal silverware to cause self harm, therefore, the nurse should arrange for the client to have only plastic products on their meal tray.
A charge nurse is planning an in-service for a group of newly licensed nurses about the use of restraints. Which of the following information should the nurse include?
Record the client's behavior every 15mins while in restraints. -Complete a written record of the client's behavior every 15mins in the client's medical record while in restraints. The client should be considered for reintegration when they are able to follow commands and exhibit self-control of behavior.
A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take?
Redirect the client attention using reality based conversation. -Using a calm voice, the nurse should provide a diversion from the hallucinations by engaging the client with simple conversation. The nurse can also encourage the client to use other diversions such as listening to music or watching television.
A nurse is assigning tasks to a licensed practical nurse and an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
Remain with a client who has anorexia nervosa following a meal. -At risk for purging following a meal. It is within the range of function of the AP to remain with the client following the meal to ensure the client complies with the plan of care and does not purge.
A nurse is caring for a client who has schizophrenia and is exhibiting violent behavior. After staff members place the client in restraints, which of the following actions should the nurse take?
Request that the provider see the client within 1hr. -Notify the clients provider of the need for restraints and request that the provider assess the client within 1hr.
A nurse is planning to teach a group of clients about techniques to change unwanted behaviors. Which of the following techniques is the nurse using when she acts out different scenarios and has clients respond by practicing new behaviors?
Role Playing. -The nurse can assign specific roles to clients and develop scripts for them to use when acting out different situations. This allows clients to see how their behavior affects others and gives them an opportunity to practice new behaviors.
A nurse is checking laboratory values for a hospitalized young adult client who has bipolar disorder and is taking lithium. Which of the following values is the priority for the nurse to report to the provider?
Serum creatinine 2.1 mg/dL -Reference range of 0.5-1.2 mg/dL. The greatest risk to this client is decreased kidney function, which can cause an increase in the client's lithium level; therefore, this value is the priority for the nurse to report to the provider. The clients lithium dosage might need to be modified based on this lab value. The cause of increased serum creatinine include dehydration as well as renal disorders. Lithium is contraindicated for clients who have severe renal disease, cardiac disease, or severe dehydration.
A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?
Sharpened perceptions. -Mild anxiety occurs daily during normal experiences and allows and individual to grasp more information and problem-solve more effectively. As stress increases, the client's perceptual field narrows and they are able to focus only on the source of the anxiety.
A nurse is planning care for a client who is taking benztropine to reduce extrapyramidal manifestations developed secondary to taking an antipsychotic medication. For which of the following adverse effects of benztropine should the nurse monitor?
Tachycardia -At risk for palpitations and tachycardia caused by anticholinergic toxicity. Common adverse effects associated with anticholinergic medications include dry mouth, blurred vision, urinary retention, constipation, photophobia, and tachycardia. Benztropine is commonly prescribed for clients who take antipsychotic agents and who are experiencing extrapyramidal effects, such as Pseudoparkinsonism with tremors, shuffling gait, and drooling or dystonia with painful contractions of the jaw or neck.
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following findings should the nurse expect?
Tachypnea -Other manifestations of withdrawal include hyperreflexia, enlarged pupils, muscle spasms, lacrimation, yawning, and rhinorrhea.
A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?
The client refuses to drink fluids. -Severe dehydration can cause cardiac arrhythmias due to fluid and electrolyte imbalances. The nurse should continue to offer the client fluids at least once per hour, and encourage the client to drink the fluids using a clean and calm tone.
A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?
This therapy will help me recognize changes in my blood pressure. -Uses a monitoring machine, to identify changes in body function. The purpose of biofeedback therapy is to enable the client to learn to consciously control body processes.
A nurse in a mental health facility is caring for a client who has frequent episodes of aggressive and violent behavior. The nurse should identify which of the following findings as indications that the client is at risk for imminent violence? SATA
Uses profanity to express emotions. Clenches and unclenches the jaw. Maintains intense eye contact. Paces the floor. -Increase in profanity can be a manifestation of escalating behavior, which can signal a violent episode. Some clients speak more loudly when they become angry, while others become very quiet or speak more softly. -As behavior escalates toward violence, the nurse might observe the client clenching and unclenching the jaw or fist, or standing with a rigid posture. -Maintaining intense eye contact or suddenly avoiding eye contact are manifestations associated with imminent violence. -Client who becomes more active or restless and paces often around the unit is at a high risk for becoming violent.
A nurse in an acute care mental health facility is caring for a client who has generalized anxiety disorder and suddenly begins pacing, wringing her hands, and reporting numbness and tingling in her fingers. Which of the following actions should the nurse take?
Walk with the client while setting physical limits on her behavior. - The client is experiencing panic level anxiety and might display unsafe behavior during this time. The nurse should stay with the client and allow her to walk around to decrease tension and anxiety.
A nurse is creating a plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
Weigh the client daily after first voiding. -Weigh the client each morning after waking and following their first voiding. The client should have nothing by mouth, including water, before obtaining the clients weight. The nurse should also assess the clients skin turgor and oral mucus membranes to ensure the client is hydrated.
A nurse is caring for a client who expresses anger and fear about the loss of a job. Which of the following responses should the nurse make?
What are some ways you can deal with the job loss? -The nurse can then encourage the client to identify a plan of action for addressing the situation.
A nurse is performing a mental status examination of a client. Which of the following questions should the nurse ask the client to assess their cognition?
What did you have for dinner last night? -The nurse can assess the client's cognitive status by asking questions that test the client's recent and immediate memory, such as what they had for dinner.
A nurse is providing information to a client who is seeking voluntary admission to a mental health facility. Which of the following information should the nurse include?
You will still need to give informed consent for treatment after admission. -A client who seeks voluntary admission to a mental health facility has the same rights as clients receiving any other kind of health care. The client will still need to give informed consent for treatment and therapies, such as electroconvulsive therapy.
A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?
You're afraid you have caused physical injury to yourself? -Repeating the main idea of what the client has said, which will allow for clarification of any misunderstanding on the part of the client or the nurse.
A nurse in an emergency department is caring for a school age child who has lacerations and bruises inflicted by his mother. The client's father states, "My wife was fired today and came home really angry. I don't think this will ever happen again." Which of the following responses should the nurse make?
Your child will be privately interviewed about the incident. -To allow the child the opportunity to discuss the situation accurately in his own words. The presence of a parent during the interview can influence the child's responses.
