Showing Page:
1/37
HESI RN MENTAL HEALTH
During admission to the psychiatric unit, a female client is extremely anxious and
states that she is worried about the sun coming up the next day. What intervention is
most important for the RN to implement during the admission process?
A. Assist the client in developing alternative coping skills.
B. Remain calm and use a matter-of-fact approach.
C. Ask the client why she is so anxious
D. Administer a PRN sedative to help relieve her anxiety. (ANS- A.
A female client is brought to the emergency department after police officers found
her disoriented, disorganized, and confused. The RN also determines that the client is
homeless and is exhibiting suspiciousness. The client's plan of care should include
what priority problem?
A. Acute confusion.
B. Ineffective community coping
C. Disturbed sensory perception.
D. Self-care deficit. (ANS- A
The occupational health nurse is working with a female employee who was just
notified that her child was involved in a MVA and taken to the hospital. The
employee states, "I can't believe this. What should I do?" Which response is best for
the RN to provide in this crisis?
A. Tell me what you think should happen.
B. How serious was the collision?
C. What do you think you should do?
D. Call for transportation to the hospital. (ANS- D
Showing Page:
2/37
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He
also reports that he is married to a female movie star and thinks that his brother
wants a sexual relationship with her. What is the priority nursing problem for
admission to the psychiatric unit?
A. Ineffective sexual patterns.
B. Impaired environmental interpretation.
C. Disturbed sensory perception.
D. Compromised family coping. (ANS- A
The RN is providing care for a client diagnosed with borderline personality disorder
who has self-inflicted lacerations on the abdomen. Which approach should the RN
use when changing this client's dressing?
A. Provide detailed thorough explanations when cleansing wound.
B. Perform the dressing change in a non-judgmental manner.
C. Ask in a non-threatening manner why the client cut own abdomen.
D. Request another staff member assist with the dressing change. (ANS- B
While sitting in the day room of the mental health unit, a male adolescent avoids eye
contact, looks at the floor, and talks softly when interacting verbally with the RN.
The two trade places, and the RN demonstrates the client's behaviors. What is the
main goal of this therapeutic technique?
A.Initiate a non-threatening conversation with the client.
B. Dialog about the ineffectiveness of his interactions.
C. Allow the client to identify the way he interacts.
D. Discuss the client's feelings when he responds. (ANS- C
An antidepressant medication is prescribed for a client who reports sleeping only 4
hours in the past 2 days and weight loss of 9 lbs within the last month. Which client
goal is most important to achieve within the first three days of treatment?
Showing Page:
3/37
A. Meet scheduled appointment with dietitian.
B. Sleep at least 6 hours a night.
C. Understands the purpose of the medication regimen.
D. Describes the reasons for hospitalization. (ANS- B
When preparing to administer to domestic violence screening tool to a female client,
which
statement should the RN provide?
A. If your partner is abusing you, I need to ask these questions.
B. State law mandates that I ask if you are a victim of domestic violence.
C. The HCP provider needs to know if you are experiencing any domestic abuse.
D. All clients are screened for domestic abuse because it is common in our society.
(ANS- D
A young adult female visits the mental health clinic complaining of diarrhea,
headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings
are within normal limits. During the physical assessment, the client tells the RN that
her sister thinks she is neurotic and calls her a hypochondriac. Which response is
best for the RN to provide?
A. Unless your sister has a medical education, ignore her comments.
B. I can hear that your sister comments are over-whelming you.
C. Do you think it's possible that you might be a hypochondriac?
D. Besides your sister's comments, what in your life is troubling you? (ANS- D
The RN is leading a group on the inpatient psychiatric unit. Which approach should
the RN use during the working phase of group development?
A. Establishing a rapport with group members.
B. Clarifying the nurse's role and clients' responsibilities.
C. Discussing ways to use new coping skills learned.
Showing Page:
4/37
D. Helping clients identify areas of problem in their lives. (ANS- D
A male client with schizophrenia is demonstrating echolalia, which is becoming
annoying to other clients on the unit. What intervention is best for the RN to
implement?
A. Isolate the client from the other clients.
B. Administer PRN sedative.
C. Avoid recognizing the behavior.
D. Escort the client to his room. (ANS- D
A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase.
Based on which assessment finding will the RN withhold the clonidine (Catapres)
prescription?
A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
B. Pulse rate of 68-78 BPM.
C. Temperature of 99.5-99.7 F.
D. Respiration rate of 24 breaths per minute. (ANS- A
The RN on the evening shift receives report that a client is scheduled for
electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn
implement the evening before the scheduled ECT?
A. Hold all bedtime medications.
B. Keep the client NPO after mid-night.
C. Implement elopement precautions.
D. Give the client an enema at bedtime. (ANS- B
A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily
is admitted to an acute care hospital for uncontrolled hypertension. What dietary
choices should the RN instruct the client to avoid?
Showing Page:
5/37
A. Pan-seared catfish.
B. Peperoni pizza.
C. Deep fried shrimp.
D. Beef trips with gravy. (ANS- B
A mental health worker is caring for a client with escalating aggressive behavior.
Which action by the mental health worker warrants immediate intervention by the
RN?
A. Is attempting the physically restrain the patient.
B. Remains at a distance of 4 feet from the client.
C. Tells the client to go to the quiet area of the unit.
D. Is using a load voice to talk to the client. (ANS- A
A client who recently experienced the death of a significant other arrives at the
mental health center. The client reports loss of interest in usual activities, expresses a
wish to be with the decreased significant other, has been eating very little, and has
not slept in several days. Which client statement is most important for the RN to
explore at this time?
A. Not sleeping for several days.
B. Wishing to be with spouse.
C. Lack of interest in usual activities.
D. Eating very little. (ANS- A
A middle aged adult with major depressive disorder suffers from psychomotor
retardation, hypersomnia, and motivation. Which intervention is likely to be most
effective in returning this client to a normal level of functioning?
A. Provide education on methods to enhance sleep.
B. Teach the client to develop a plan for daily structured activities.
C. Suggest that the client develop a list of pleasurable activities.
Showing Page:
6/37
D. Encourage the client to exercise. (ANS- B
When developing a plan of care for a client admitted to the psychiatric unit following
aspiration of a caustic material related to a suicide attempt, which nursing problem
has the highest priority?
A. Impaired comfort.
B. Risk for injury.
C. Ineffective breathing pattern.
D. Ineffective coping. (ANS- C
A female client on a psychiatric unit is sweating profusely while she vigorously does
push- ups and then runs the length of the corridor several times before crashing into
furniture in the sitting room. Picking herself up, she begins to toss chairs aside,
looking for a red one to sit in. When another client objects to the disturbance, the
client shouts, "I am the boss here. I do what I want." Which nursing problem best
supports these observations?
A. Deficient diversional activity related to excess energy level.
B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity. (ANS- B
A RN is preparing the physical environment to interview a new client for admission
to the mental health unit. Which environmental setting facilitates the best outcome of
the interview?
A. Dim the lights in the room to help the patient feel calm.
B. Sit within two feet of the client to enhance level of safety and security.
C. Reduce the noise level in the room by turning off the television and radio.
D. Position table between the client and the RN for extra personal space. (ANS- C
Showing Page:
7/37
An older homeless client visits the psychiatric clinic to obtain a prescription renewal
for alprazolam (Xanax). During the health assessment, the client complains of chest
pain. Which action should the RN take first?
A. Refer the client to the cardiology unit.
B. Obtain the client Blood pressure.
C. Assess the client for substance abuse.
D. Determine if Xanax was taken recently. (ANS- D
The mother of an 8-month-old infant with profound mental and physical disabilities
tells he RN how depressed she is because she realized that her child will never
achieve normal growth and development milestones. How should the RN respond to
the mother?
A. Ask the mother if she has ever thought about harming herself or her child.
B. Reassure the mother that her child will achieve some growth and development
milestones.
C. Determine if the mother has other children who do not have developmental
disabilities.
D. Encourage the mother to write thoughts and feelings in journal. (ANS- A
Several clients with chronic mental illness and multiple substance abuse histories
live in a group residential home and attend daycare mental health facility where
group and individual therapies are provided. The RN finds the common bathroom at
the facility with sputum on the walls, urine in the sink and on the floors, and the
toilet stopped up with tissue, paper towels, and feces. What is the priority issue that
the RN should address?
A. Medication non-compliance.
B. Number of bathroom facilities.
C. Infection control.
D. Acting out behaviors. (ANS- C
Showing Page:
8/37
A client with schizophrenia is admitted to the psychiatric care unit for aggressive
behavior, auditory hallucinations, and potential for safe harm. The client has not
been taking medications as prescribed and insists that the food has been poisoned
and refuses to eat. What intervention should the RN implement?
A. Assure the client that all food served in the hospital is safe to eat.
B. Tell the client that irrational thinking is a symptom of schizophrenia.
C. Obtain an order for a tube feeding for the client.
D. Provide the client with food in unopened containers. (ANS- D
The RN is providing education about strategies for a safety plan for a female client
who is a victim of intimate partner violence. Which strategies should be included in
the safety plan? (SOA) SELECT ALL:
A. Purchase a gun to use for protection.
B. Establish a code with family and friends to signify violence.
C. Take a self-defense course that retaliates the abuser with injury.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit. (ANS- B, D, E
The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day.
Which information should the RN report to the HCP immediately?
A. Short term memory loss.
B. Five pound weight gain
C. Decreased affect.
D. Nausea and vomiting. (ANS- D
A male client who is admitted with delirium tremens is dehydrated and experiencing
auditory hallucinations. He has a bruised, swollen tongue and is confused. In
Showing Page:
9/37
developing a plan of care, which action should the RN include to ensure the client is
physiologically stable?
A. Encourage oral fluids.
B. Monitor vital signs.
C. Keep the room dark.
D. Apply ice to his tongue. (ANS- B
A RN is teaching a client about initiation of a prescribed abstinence therapy using
Disulfiram (Antabuse). What information should the client acknowledge
understanding?
A. Admit to others that he is a substance abuser.
B. Remain alcohol free for 12 hours prior to first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Completely sustain from heroin or cocaine use. (ANS- B
The RN is working with a male client at a community mental health center when the
client reports hearing voices that tell him to get a knife from the kitchen and hurt
himself. What intervention is most important for the RN to implement?
A. Don't allow the client to go into the kitchen until the hallucination has subsided.
B. Report the behavior to the client's case workers so that the family can be notified.
C. Assign the UAP to remain with the client at all times.
D. Document the behavior in the client's record and notify the HCP. (ANS- C
A homeless client who reports feeling sad and depressed tells the mental health nurse
that in the past 2 days she has only had 4 hours of sleep. Which action is most
important for the RN to implement within the first 24 hours after treatment is
initiated?
A. Allow the client to rest and sleep.
B. Ensure client attend groups addressing coping skills for dealing with depression.
Showing Page:
10/37
C. Begin planning for the clients discharge.
D. Encourage verbalization of feelings. (ANS- A
Which client statement suggests the RN that the client is using a defense mechanism
of projection to deal with anxiety related to admission to a psychiatric unit?
A. At least I hit the wall instead of hitting the psychiatric aide.
B. I am here because the police thought I was doing something wrong.
C. I want to be here because I know it is the best psychiatric facility. D. Don't believe
everything my family tells you, I am not crazy. (ANS- B
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh
wound after attempting to shoot himself. He was divorced one year ago. Lost his job
four months ago, and suffered a breakup of is current relationship last week. What is
most likely source of this client's current feelings of depression?
A. Feelings of frustration.
B. A sense of loss
C. Poor self-esteem.
D. A lack of intimate relationships. (ANS- B
The RN documents the mental status of a female client who has been hospitalized for
several days by court order. The client states" I don't need to be here," and tells the
RN that she believes that the t.v talks to her. The RN should document these
assessment statements in which section of the mental status exam?
A. Insight and judgement.
B. Mood and affect.
C. Remote memory.
D. Level of concentration. (ANS- A
Showing Page:
11/37
An older ale client with schizophrenia is found smearing feces n the bathroom walls
of the chronic mental health unit where he resides. What action should the RN
implement?
A. Explain that the feces belong in the toilet.
B. Show the client how to clean the walls.
C. Escort the client out of the bathroom.
D. Assist the client to clean the walls. (ANS- C
A male client tells the RN that he does not want to take the atypical antipsychotic
drug, olanzapine (Zypexa), because of the side effects he experienced when he took
the drug for a year. Which experience is most likely related to taking olanzapine?
A. Weight gain of 75 lbs.
B. Thoughts of wanting to hurt himself.
C. Frequent days with diarrhea.
D. Alerted liver function test. (ANS- A
A college student who is a victim of a car-jacking presents to the community health
center and report increased anxiety. During the interview, what nursing intervention
should take the highest priority?
A. Identify support systems in the community that may be helpful.
B. Help the client feel safe to decrease anxiety.
C. Ask the client to describe coping strategies that were helpful in the past.
D. Encourage the client to verbalize anxiety related to event. (ANS- B
The RN completes an assessment of a client who is experiencing intimate partner
violence (IPV). Which finding of the injuries should the RN include in the
documentation?
A. A summary of the client's feelings.
B. Photographs.
Showing Page:
12/37
C. A general description.
D. A client's significant other's statement. (ANS- B
Following involvement in a MVC, a middle aged adult client is admitted to the
hospital with multiple facial fractures. The client's blood alcohol level is high on
admission. Which PRN prescription should be administered if the client begins to
exhibit signs and symptoms
of delirium tremens (DTs)?
A. Prochlorperazine (Compazine) 5 mg IM.
B. Hydromorphone (Dialuadid) 2 mg IM.
C. Chlorpromazine (Thorazine) 50 mg IM.
D. Lorazepam (Ativan) 2 mg IM. (ANS- D
A male adult comes to the mental health clinic and walks back and forth in front of
the office door, but does not enter the office. He then walks around a chair that is in
the hallway several times before sitting down in the chair. What action should the
nurse take first observe (ANS- the client in the chair
A female client engages in repeated checks of door and window locks. Behavior that
prevents her from arriving on time and interferes with her ability to function
e2ectively. What action should the nurse take (ANS- plans a list of activities to be
carried out daily
A male client with schizophrenia is admitted to the mental health unit after abruptly
stopping his prescription for ziprasidone (Geodon) one month ago. Which question is
most important for the nurse to ask the client (ANS- Do you hear voices
A female client with a history of drinking who was admitted 8 hours ago after
receiving treatment for minor abrasions occurred from a fall at home.The nurse
Showing Page:
13/37
determines the client's blood alcohol level (BAL) was not analyzed on administration
action should the nurse take (ANS- ask client about alcohol quantity, frequency, and
time of last drink
Which client statement suggests to the nurse that the client is using the defense
mechanism of projection to deal with anxiety related to admission to a psychiatric
unit (ANS- i am here because the police thought i was doing something wrong
A female client on a psychiatric unit is sweating profusely while she vigorously does
push- ups and then runs the length of the corridor several times before crashing into
the furniture in the sitting room. Picking herself up, she begins to toss chairs aside,
looking for a red one to sit in. When another client objects to the disturbances, the
client shouts," I am the boss here. I do what I want." Which nursing problem best
supports these observations? (ANS- risk for other related violence related to
disruptive
What is the most important goal for a client diagnosed with major depression who
has been receiving an antidepressant medication for two weeks (ANS- not attempt
suicide
Admission A female client with a history of drinking who was admitted 8 hours ago
after receiving treatment for minor abrasions occurred from a fall at home. The nurse
determines the client's blood alcohol level (BAL) was not analyzed on administration
action should the nurse take Blood alcohol level (ANS- ask the client about alcohol
quantity, frequency, and time of last drink
IPV- difficulty leaving victim of intimate partner violence what 3 things should you
do (ANS- 1. establish a code with family and friends to signify violence
2. plan an escape route to use if the abuser blocks main exit
Showing Page:
14/37
3. have a bag ready that has extra clothes for self and children
Anger Management Give the client (ANS- permission to be angry
The nurse is assessing a client who is believed to have a borderline personality
disorder. Which question is most important to include in this assessment? (ANS- Do
you frequently have temper tantrums?
After returning to work after a weekend off the nurse gets report that a depressed
client has been in bed all weekend. What should the nurse to first? (ANS- assist the
client out of bed and involve in activity
A client with dementia uses the defense mechanism of confabulation. What is the
reasoning? (ANS- to decrease anxiety
A husband states to the nurse that his wife is not sleeping, buying impulsively, taking
last minute trips, and has lost 22 pounds one month. What is an appropriate nursing
dx? (ANS- disturbed thought process
A nurse is explaining a fire drill routine to a group of clients. A client becomes
disruptive and continually interrupts the group. What is the nurse's best response?
(ANS- when you interrupt, i cannot explain what to do to the group
When performing a MSE on a client which assessment intervention would best assist
the nurse? (ANS- ask the client to interpret the proverb, "a stitch in time saves nine"
A client comes in after being in a car accident and is experiencing alcohol
withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give
first? (ANS- magnesium
Showing Page:
15/37
A woman is just told of her husband's dx of terminal cancer. What would the nurse
offer for the spouse (wife)? (ANS- How would you like to be involved in your
husband's care?
A nurse is to remove staples from an abdominal incision, the client is very anxious.
What is the most important intervention? (ANS- attempt to distract the client with
general conversation
A man dx with bipolar disorder states, "I don't understand, I believe in God and have
not done anything to deserve this". What is the nurse's best response? (ANS- you
didnt do anything wrong. you have a chemical imbalance in your brain
A client becomes upset when the nurse he requests is not assigned to him, what is the
nurse's best response? (ANS- advise the client that the nursing assisngments are not
based on client requests
A client needs to wash her hands for two hours before able to go on with her
morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty.
What is this mechanism? (ANS- compulsion
A client in group is talking about her prostitution, the nurse asks her if she was
abused by her parents. She states "my mother ran my father out when I was young".
What defense mechanism was used? (ANS- repression
A woman calls the crisis hotline and says she has a loaded gun and is going to kill
herself. To
maintain patient confidentiality what would the nurse do? (ANS- contact the person
the client chooses to go to the home and remove the weapon
Showing Page:
16/37
A client with anger management issues uses belt making and bangs the leather
heavily. What defense mechanisms is being used? (ANS- sublimation
Who is most prone to being abused (elder abuse)? (ANS- Females over 75 living
with their families.
client in the dayroom had tipped over a table and is escalating and has picked up a
chair which he is threatening to throw at another client. What should the nurse do
first? (ANS- go and get more staff assistance
A woman who is psychotic is carrying all of her belongings around with her because
she is afraid that someone will steal it. What is the best way to establish trust? (ANS-
make brief contact with the client throughout the day
In adolescent group discussing a handout on anger management, a client is becoming
increasingly interruptive and talking about his home and pets. What is the nurse's
most appropriate response? (ANS- redirect the client to read the handout
What is the most important intervention for a client with bulimia? (ANS- plan
scheduled meals
A client comes into the ED with DTs. What should the nurse do first? (ANS-
administer ativan
What are the side effects of Resperdal? (ANS- Fever, tachycardia, and sweating.
Showing Page:
17/37
A client who is refusing to take his medication is wandering on the unit and going in
and out of resident's rooms. What is the priority? (ANS- wandering in and out of
other client's rooms
A nurse observes a client in the dayroom talking to himself. What should the nurse
do first? (ANS- ask the client if he's currently hearing voices
A client comes to the nurses' station and told the nurse that her roommate had cut her
wrists in the bathroom. After assessing and dressing the wounds, what should the
nurse do next? (ANS- move the client to a private room by the nurses station
A man comes into the ER after being in a car accident with an alcohol level greater
than 2, what should the nurse prepare to administer? (ANS- Ativan or librium per
facility policy
What would be proper teaching for a client who is to start taking Antabuse? (ANS-
has not had anything alcoholic to drink for the last 48 hours
Alzheimer's patient-nurse goes to do dressing change and the client refuses. What
should the nurse do? (ANS- leave and come back 30 minutes later
A client is confused in an acute care hospital setting. What would support the dx of
delirium instead of dementia? (ANS- delirium: started in hospital
An elderly woman is brought to the ER with multiple stages of healing bruises. What
should the nurse do? (ANS- Take the woman aside and ask about her abuse
A business man is stressed about his finances, has anxiety and sleeplessness. (ANS-
Limit intake of sugar and caffeine
Showing Page:
18/37
A mother comes into the clinic with her son who is being accused of a crime. She is
worried her son will go to jail. What should the nurse say to the mother? (ANS-
Consequences of enabling behaviors
What is a common side effect of cocaine use? (ANS- MI
A client on LSD comes into the ER. How do you approach the client? (ANS- Talk
calmly and soothing to the client
A client taking Meth and Benzo's, what would the nurse prepare to do for overdose?
(ANS- give narcan
An alcoholic father tells his wife and children to stay away from him. What is the
most important nursing dx? (ANS- Risk for injury
What should you advise a patient a MAOI not to eat? (ANS- Cheese, beer, &
avacado
The parents of a teenager who has overdosed what is the first question to ask? (ANS-
What drug did the client ingest?
A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3
days. What should the nurse do? (ANS- Take to quiet room and give PB crackers
A client with a hx of depression and abusing alcohol with their depression getting
worse. What is the most important nursing dx? (ANS- Ineffective coping
Showing Page:
19/37
A woman is being abused by her husband, the abuse is escalating. What would the
nurse ask first? (ANS- Do you have a plan in place when you are not safe?
SAFETY!
A patient has stopped taking Depakote six months ago, what would the nurse assess?
(ANS- Mood
A client with Alzheimer's keeps asking for his mother. What is the nurse's
appropriate response? (ANS- Your mothers not here but you are safe
A client is told to come in by friends, client's complaints include losing his job, just
got a divorce, single dad with two kids, what would be the best question for nurse to
ask? (ANS- What is troubling you the most?
What are the side effects of Lithium? (ANS- Dehydration, diarrhea, and thirstiness.
A client with an anxiety disorder is demonstrating signs of panic. Which intervention
would be the most appropriate for the nurse to implement (ANS- Decrease
environmental stimuli and interaction with other people
client tells the nurse that he is an accomplished writer and that directors of television
shows contact him for suggestions on actors and locations. The nurse realizes this
client is experiencing the delusion of (ANS- grandiosity
A client tells the nurse that his father died after the client thought abut it for a few
days. The nurse suspects the client is delusional and is demonstrating: (ANS-
magical thinking
Showing Page:
20/37
The nurse overhears a client diagnosed with terminal cancer tell a family member
that he will be discharged soon, will return to work, and plans to attend a company
event scheduled in a year. The nurse realizes this client is demonstrating the defense
mechanism of (ANS- denial
A female client diagnosed with depression tells the nurse that her husband wants her
to "fix herself up" and put on nice clothes. The client continues by saying that she
believes her husband is interested in another woman. What should the nurse respond
to the client? (ANS- I can help you shower and get dressed before he comes to visit
A client diagnosed with schizophrenia has been refusing prescribed oral medication
for several days. The client has broken chair and is coming after another client with
the broken chair leg, threatening to do physical harm. What should the nurse do first?
(ANS- Remove the other client from the room
The nurse has identified the diagnosis imbalance Nutrition: More than body
requirements for a client diagnosed with bulimia. Which intervention would be
appropriate for this diagnosis? (ANS- Help client assess situations that precedes
binginh
A client tells the nurse that he has a fear of flying on an airplane but needs to attend a
work- related meeting in another part of the country and will have to fly to get there.
What can the nurse do to assist this client? (ANS- Instruct the client to visualize
flying to the meeting destination
During an assessment, a client from the Hispanic culture refuses to maintain eye
contact with the nurse. After the nurse overhears the client say "evil eye" to a family
member, the nurse realizes the client is demonstrating characteristics of which
cultural-specific syndrome? (ANS- Induced by witchcraft
Showing Page:
21/37
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh
wound after attempting to shoot himself. he is recently divorced one year ago, lost
his job four months ago, and suffered a break up of his current relationship last week.
What is the most likely source of this client's current feelings of depression? (ANS- a
sense of loss
A male client in the mental health unit is guarded and vaguely answers the nurse's
questions. He isolates to his room and sometimes opens the door to peek into the
hall. Which problem can the nurse anticipate (ANS- delusions of persecution
A male client who is seen in the mental health clinic monthly reports feeling very
stressed and nervous and further describes becoming angry increasingly more often
during the last month. What action should the nurse take first (ANS- ask the client to
identify problems that have occurred during the last month
A 26-year-old female client has been particularly restless and the nurse finds her
trying to leave the psychiatric unit. She tells her the nurse," please let me leave
because the secret police are after me." Which response is best for the nurse (ANS-
come with me to your room and i will sit with you
The nurse is preparing medications for a client with bipolar disorder and notices that
the antipsychotic medication was discontinued several days ago. Which medication
should also be discontinued (ANS- Benztropine (Cogentin)
A young woman is preparing to be discharged from the psychiatric unit. Which
nursing intervention is most important for the nurse to include in this phase of the
nurse client relationship (ANS- explore the clients feelings related to discharge
Showing Page:
22/37
A female high school teacher who was a child of alcoholic parents seeks counseling
at the community health clinic because of depression over a student who was killed
by a drunk driver. After several weeks of counseling, which behavior is the best
indicator that the client is coping well with the anxiety related to the student's death
(ANS- become the faculty sponsor for students against drunk driving (SADD)
A male client arrives at the mental health clinic and asks the nurse for more lithium
and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his
assessment findings with the healthcare provider, a serum creatinine is obtained.
What information supports the reason for this laboratory test (ANS- lithium is
secreted by the kidneys and creatinine is related to kidney function
A client with schizophrenia who is taking Haldol begins exhibiting tremors of the
extremities. Which intervention should the nurse implement (ANS- consult with the
provider about reducing the dosage
A male client with bipolar disorder tells the nurse that he needs to "make some deals
so that he can improve his retirement savings." Based on this information, which
client outcome should the nurse include in the plan of care (ANS- delay business
decisions until his mania subsides
one on one session and nurse begins to get angry at patient (ANS- terminate session
patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact
healthcare provider before giving (ANS- tylenol
. antidepressant side effects (ANS- dry mouth, blurred vision, constipation
Showing Page:
23/37
A woman who started chemotherapy three days ago for cancer of the breast calls the
clinic reporting that she is so upset she cannot sleep. The client has several PRN
medications available. Which drug should the nurse instruct her to take? (ANS-
Lorazepam 8mg PO HS
A male adult is admitted because of an acetaminophen (Tylenol) overdose. After
transfer to the mental health unit, the client is told he has liver damage. Which
information is most important for the nurse to include in the client's discharge plan?
(ANS- do not take any OTC meds
The nurse documents the mental status of a female client who has been hospitalized
for
several days by court order, The client states, "I don't need to be here" and tells the
nurse that she believes that the television talks to her. The nurse should document
these assessment findings in which section of the mental status exam? (ANS- insight
and judgement
depressed mother and daughter speaks in group (ANS- i hear you say you worry
about your mother's distress
A client who has agoraphobia (a fear of crowds) is beginning desensitization with the
therapist, and the nurse is reinforcing the process. Which intervention has the highest
priority for this client's plan of care? (ANS- establish trust by providing calm, safe
environment
When a male client is asked about his reason for coming to the mental health clinic
he replies, "It all started because I work in a hostile work environment. My boss
would not let me go to a religious service, so I went to human resources, and they
didn't want to do anything. It has been a really difficult time for me." Which response
Showing Page:
24/37
should the nurse provide? (ANS- "Have the feelings associated with these events
brought you to the clinic?"
ECT therapy non responsive (ANS- have you taken erectile dysfunction meds
adolescent teen interrupts group about pets at home (ANS- redirect him
postpartum depression Sign & Symptoms (3) (ANS- distrubed sleep, sadness, poor
concentration
ECT (ANS- NPO after midnight
health assessment of history of alcohol dependency WHAT ELSE WOULD BE A
CONCERN (ANS- pancreatitis
knee surgery post op and diaphoretic and visual hallucinations (ANS- obtain VS
aspiration due to caustic material related to suicide attempt (ANS- ineffective
breathing pattern
A 38-yea- old female client is admitted with a diagnosis of paranoid schizophrenia.
When her tray is brought to her food to eat and tells the nurse, "I know you are trying
to poison me with that food." Which response would be most appropriate for the
nurse to make? (ANS- "ill leave your tray here. I am available if you need anything
else"
A client with paranoia is admitted to the mental health unit and immediately goes to
the corner of the room and sits quietly without communicating. In approaching the
Showing Page:
25/37
client, what intervention should the nurse implement first? (ANS- explain the nurse's
role to the patient
A client comes out dressed in short skirt, low top, bright red lipstick. what should the
nurse do? (ANS- assist back to their room and help pick out appropriate clothing
A client comes in and is 5'5, 75lbs. what should the nurse do? (ANS- start an IV for
IV resuscitation
A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a
day." What can the nurse determine from this statement? (ANS- parent is exhibiting
tolerance to alcohol
2 days after admission from alcohol withdrawal what should the nurse do? (ANS-
monitor HR and BP
DO NOT IMPLEMENT SEIZURE PADS
Something about a male client threatening a teacher or becomes upset with teacher
(ANS- methods of clearly communicating ***
Patient says I'm going to shoot myself" (ANS- stop client from leaving the unit
History of alcoholism admitted for detoxification; 6mg of Ativan what additional
prescription administer immediately (ANS- vitamin B1 (thiamine)
PTSD admitted to psychiatric unit, which intervention is most important for plan of
care (ANS- provide quiet room, away from rec area
Showing Page:
26/37
Chronically depressed older male client of a long term care facility becomes more
reclusive and today refuses to leave room (ANS- may i sit with you for a while?
Male client on atypical antipsychotic drug olanzapine(Zyprexa) Adverse reaction is
weight gain (ANS- client sitting in corner of day room during admission assessment,
what nursing action?
ask client simple questions
How do you take Antabuse? (ANS- each morning beginning 48 hours after your last
drink of alcohol
The nurse is using the CAGE questionnaires as a screening tool for a client who is
seeking help because his wife said he had a drinking problem. What information
should the nurse explore indepth with the client based on this screening tool?
A. Consumption, liver enzyme, gastrointestinal complains and bleeding.
B. Minimizes drinking frequently misses family events, guilt about drinking, and
amount of daily intake.
C. Cancer screening results, anger, gastritis, daily alcohol intake.
D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener".
(ANS- D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-
opener". (Cutting down, annoyance, guilt and eye-opener drinking are represented
with the acronym of CAGE)
A client who is admitted with a closed head injury after a gall has a blood alcohol
level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the
first 6 hours following admission should the nurse identify as the priority?
A. Place in a side-lying position with head of bed elevated.
B. Administer disulfram (Atabuse ) immediately
Showing Page:
27/37
C. Give lorezapam (Ativan)PRN for signs of withdrawal.
D. Provide thiamine and folate supplements as prescribed. (ANS- A
(Maintain patient's airwat is the priority for a client who is intoxicated and obtunded)
The nurse is preparing medications for a client with bipolar disorder and notices that
the antipsychotic medication was discontinued several day ago. Which medication
should also be discontinued?A. Alprazolam (Xanax)
B. Benztropine (Cogentin)
C. Magnesium (Milk of Magneisa)
D. Lithium (Lathotbabs) (ANS- B
(Cogentin is given with traditional antipsychotic medications to reduce
extrapyramidal side effects and should be discontinued when the antipsychotic
medication is discontinued)
The nurse leading a group session of adolescent clients give the members handout
about anger management. One of the male clients is fidgety, interrupts peers when
they try to talk, and talks about his pets at home. What nursing action is best for the
nurse to take?
A. Give the client permission to leave and return in 10 minutes.
B. Explore the client's feeling about his pets and home life.
C. Encourage his peers to help involve him in the activity.
D. Redirect him by encouraging him to read from the handout. (ANS- D. Redirect
him by encouraging him to read from the handout.
(Best nursing action is to ask the client to read from the handout)
A male client is admitted to the psychiatric unit for recurrent negative symptoms of
chronic schizophrenia and medication adjustment of risperidone (Risperdal). When
the client walks to the nurse's station in a laterally contracted position, he states that
Showing Page:
28/37
something has made his body confort into a monster. What action should the nurse
take?
A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril)
B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
D. Direct client to occupational therapy to distract him from somactic complaints.
(ANS- C
(The client is experiencing a dystonic reaction due to dopamine depletion, one of the
physiologic actions of Risperidone. This side effect requires immediate management
with Cogentin )
A middle-aged adult with major depressive disorder suffer from psychomotor
redardation, hypersomnia, and amotivation. Which intervention is like to be most
effective in returning this client to a normal level of functioning?
A. Encourage the client to exercise.
B. Suggest that the client develop a list of pleasurable activities.
C. Provide education on methods to enhance sleep.
D. Teach the client to develop a plan for daily structured activities. (ANS- D. Teach
the client to develop a plan for daily structured activities.
(Development of structure life-style is vital when a client is having difficulty with
psychomotor retardation, amotivation and hypersomnia)
A male client with a long history of alcohol dependency arrives in the Emergency
department describing the feeling of bugs crawling on his body. His blood pressure is
170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which
prescription should the nurse administer?
A. Haloperidol (Hadol)
B. Thiamine (Vitamin B1)
C. Lorazapam (Ativan)
Showing Page:
29/37
D. Diphenhydramine (Benadryl) (ANS- C
(A client with a history of alcohol dependency can experience delirium tremors
within 72 to 96 hours after alcohol abstinence. Ativan should be given to decrease
central venous systems excitation (restlessness, agitation, seizures)
The nurse is teaching a client about the initiation of a prescribed abstinence therapy
using disulfiram (Antabuse). What information should the client acknowledge
understanding?
A. Completely abstain from heroin or cocaine use.
B. Attend monthly meetings of alcoholic anonymous.
C. Remain alcohol free for 12 hours prior to the first dose.
D. Admit to others that he is a substance abuser. (ANS- C
(The client must be alcohol free for 12 hours before the beginning of Antabuse
therapy to avoid the precipitation of a dusulfiram reaction, an aversive effects)
A female client reports feeling hopeless and is unable to stop crying. She explains
that she is worried about losing her job. Since the client's husband recently lost his
job she feels her employmemt is essential to the family's survival. To evaluate the
effectiveness of cognitive-behavioral techniques, which client outcomes should the
nurse include in the plan of care?
A. Relates insight into problematic relationships
B. Demonstrates a healthy relationship with husband.
C. Described how the family can resolve problem.
D. Changes thought patterns related to problem solving. (ANS- D
(Cognitive-behavior therapy focuses on changing thought pattern by directing the
client to problem solving the present situation)
Showing Page:
30/37
A female client engages in repeated checks of door and window locks, behavior that
presents her from arriving on time and interferes with her ability to function
effectively. What action should the nurse take?
A. Discuss checking the time frequently
B. Ask the client why she checks the locks
C. Plan a list of activities to be carried out daily.
D. Determine the type and size of the locks. (ANS- C
(Helps the client to gain recognition of and insight into the anxiety and assists her to
learn new adaptive coping behaviors)
A male client with schizophrenia is demonstrating echolalia, which is becoming
annoying to other clients on the unit. That intervention is best for the nurse to
implement?
A. avoid recognizing the behavior.
B. Isolate the client from other clients.
C. Administer a PRN sedative.
D. Escort the client to his room. (ANS- D
(Echolalia, constantly repeating what others are saying, can become disruptive to a
community environment, so the nurse should direct the client to a private space such
as his room)
A young adult male is hospitallizaed due to depression and an attempted suicide
attempt. The client reports that he lost his job and was angry with his employer for
firing him when he took an overdose of pain medications. Which behavior best
indicates to the nurse that his condition is improving?
A. Initiates interactions with other clients.
B. Describes verbally when he is angry
C. Participates in a job search with a social worker.
D. Denies plans to harm himself or others. (ANS- A
Showing Page:
31/37
(The best indicator of improvement in a client with depression is initiated interaction
with others because such behavior indicates that the client is less withdrawn and
more self-directed)
The nurse is completing the admission assessment of an underweight adolescent who
is admitted to a psychiatric unit with a diagnosis of depression. Which finding
requires notification to the healthcare providers
A. Body mass index of 21
B. Potassium level of 2.9 mEq/dl
C. WBC of 10,000 mm3
D. Blood pressure of 110/70 mmHg. (ANS- B
( The nurse should inform the healthcare provider of potassium level of 2.9 mEq/dl,
which could be caused by electrolyte imbalance)
Following involvement in a motor vehicles collision, a middle-aged adult client is
admitted to the hospital with multiple facial fractures, The client's bold alcohol level
is high on admission. Which PRN prescription should be administered if the client
begin to exhibits signs and symptoms of delirium tremors (DT)?
A. Hydromorphone (Dilaudid) 2mg IM
B. Prochloperazine (Compazine) 5mg IM
C. Chlopronmazine (Thorazine) 50 mg IM
D. Lorazepam (Ativan) 2mg IM. (ANS- D
(Ativan is often used to treat DT and of the PRN prescriptions listed, is the treatment
of choice)
A female client, who is wearing dirty clothes and has afoul body odor, comes to the
clinic reporting feeling scared because she is being stalked. What action is most
important for the nurse to take?
A. Assure client that the healthcare provider will see her today.
Showing Page:
32/37
B. Recommend that the client talk with a social worker.
C. Ask the client to describe why she is being stalked.
D. Offer the client a safe place to relax before interviewing her. (ANS- D
(The client is demonstrating fear related to an underlying metal disorder, and she
needs to feel safe before anything is required of her)
A male client with known auditory hallucinations begins talking loudly and gesturing
wildly while in the unit's day room. What action should the nurse implement first?
A. Administer a PRN sedative.
B. Sit in the chair next to the client.
C. Escort the client to his room.
D. Listen to what the client is saying. (ANS- D
(Auditory hallucination can have various meanings to the client. Listening to what
the client is saying helps the nurse determine the type of response that is required
based on the hallucinatory messages the client is receiving)
A teenager who has lost 20 pounds in the last three months is admitted to the hospital
with hypotension and tachycardia. The client reports irregular menses and hair loss.
Which intervention is most important for the nurse to include in the clients plans of
care?
A. Initiate caloric and nutritional therapy.
B. Implement behavioral modification therapy.
C. Evaluate the client for low self-esteem.
D. Record daily weights and graft trend. (ANS- A
(The client presents with evidence of anorexia nervosa resulting from self-starvation,
which is a life-threatening condition. Providing nutrition and calories is the priority
intervention so that the risk of electrolyte imbalance and severed dehydration can be
reduced)
Showing Page:
33/37
The nurse is developing unit policies that will include nursing guidelines for
maintaining a therapeutic milieu. Which interventions should be included when
providing a therapeutic milieu in an inpatient setting?
A. Opportunities to contribute to one's treatment plan.
B. One on one dialogue sessions with the therapist.
C. Regularly scheduled unit activities for peer interaction.
D. Home visits to reintergrate into the family. (ANS- C
(The nurse is responsible for maintaining a therapeutic milieu which provides a
secire and structure environment that promotes client's safety, provide opportunities
for the client to learn healthy coping skills)
After receiving treatment for anorexia, a student asks the school nurse for permission
to work in the school cafeteria as part of the school's work study program. What
action should the nurse take?
A. Recommend assignment to the receptionist's office.
B. Suggest that the student work in the athletic department.
C. Refer the student to a psychiatrist for further discussion.
D. Determine the parent's opinion of the work assignment (ANS- A
(Client with anorexia are obsessed with food and exercise, which often trigger self
indulgence. Assignment to the receptionist's office decreases the opportunity for the
student to be distracted with obsession associated with anorexia)
A middle-aged remale client with no previous psychiatric history is seen in the
mental health clinic because her family describes her as having paranoid thoughts.
On assessment, she tells the nurse "I want to find out why these people are stalking
me" which response should the nurse provide?
A. "It sounds like this experience is frightening for you"
B. "What makes you think people are stalking you?'
C. "I know you are frightened, but no one is stalking you"
Showing Page:
34/37
D. "Do you think someone is trying to harm you" (ANS- A
(The nurse should respond to the client's fear without addressing the delusion.)
A male veteran who recently returned from a war zone has post traumatic stress
disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal
ideation. On admission, the client's family informed the HCP that therapy sessions
did not seem to be helping. Select only one intervention that as the highest priority?
A. Administer paraxeitne 40 mg as prescribed.
B. Develop a list of therapy programs.
C. Remove all shaving equipment.
D. Determine if client has a suicide plan. (ANS- C
(Keeping the client safe is priority, so suicide precautions should be implemented, C
is priority)
A male adolescent was admitted to the unit two days ago for depression. When the
mental health nurse tries to interview the client to establish rapport, he becomes very
irritated and sarcastic. Which action is best for the nurse to take?A. Offer to play a
game of cards with the client.
B. Report the behavior to the next shift.
C. Document the behavior in the chart.
D. Plan to talk with the client the next day. (ANS- A
(Playing a game with the adolescent will establish rapport because adolescent usually
communicate more easily if involve in an activity)
Which client statement suggests to the nurse that the client is using the defense
mechanism of projection to deal with anxiety related to admission to a psychiatric
unit.
A. " I am here because the police thought I as doing something wrong"
B. "At least I hit the wall instead of hitting the psychiatric aide"
Showing Page:
35/37
C. "I want to be here because I know it is the best psychiatric facility"
D. "Don't believe everything my family tells you, I am not crazy" (ANS- A
(Blaming others for unacceptable desires, thought, shortcomings or mistakes is using
the defense mechanism of projection)
A female high school teacher who was a child alcoholic parents seeks counseling at
the community health clinic because of depression over a student who was killed by
a drunk driver. After several weeks of counseling, which client behavior is the best
indicator that the client is coping well with anxiety related to the student's dealth?
A. Signs a safety contract with the nurse agreeing not to hurt herself or others
B. Confront her parents about the hurt she felt as achild of alcoholic parents.
C. Becomes the faculty sponsor for Student Against Drunk Driving (SADD)
D. Describes alternatives to becoming depressed over the student's death. (ANS- C
(C is a method if channeling anxiety and denotes an adaptive behavior to a crisis
situation)
While interviewing a client, the nurse takes notes to assist with accurate
documentation later. Which statement is most accurate regarding note-taking during
an interview?
A. The nurses' ability to directly observe the client's non verbal communication is
limited with note takes
B. Taking notes during an interview is a legal obligation of the examining nurse.
C. The client's comfort level is increased when the nurse breaks eye contact to take
note to take note.
D. The interview process is enhanced with note taking and allows the client speak at
normal pace. (ANS- A
(Although note-taking is important, particularly when a detailed report is vital to the
assessment, note-taking requires a break in eye contact and impedes the nurse's
observation of the client's nonverbal behavior)
Showing Page:
36/37
An adolescent make receives a prescription for an antidepressant drug because he is
exhibiting a depressed affect. While the client is taking the antidepressant, which
comparison of the client's behavior before and after taking the drug is most important
for the nurse to obtain?
A. His appetite.
B. The emotional quality of his attitude
C. His level of activity.
D. The interactions he has with others. (ANS- B
(The most important assessment is related to mood or the emotional quality of his
attitude so the nurse should assess for the presence of depressed mood and suicide
ideation)
While setting in the dayroom of the mental health unit, a male adolescent avoids eye
contact, looks at the floor, and talks softly when interacting verbally with the nurse.
The two trade places, and the nurse demonstrate the client's behavior. What is the
main goal of this therapeutic techniques?
A. Discuss the client's feeling when he responds.
B. Allow the client to identify the way he interacts.
C. Initiate a non-threatening conversation with the client.
D. Dialog about the ineffectiveness of his interactions. (ANS- B
(The nurse is using role-playing to help the client identify his behavior when
interacting with others, B which provides an opportunity for the client to rehearse
assertive interactions)
A client on the mental health unit is becoming more agitated, shouting at the staff,
and pacing in the hallway. When a PRN medication is offered, the client refuses the
medication and defiantly sits on the floor in the middle of the unit hallway. What
nursing intervention should the nurse implement first?
Showing Page:
37/37
A. Transport of the client to the seclusion room.
B. Take other clients in the area to the client lounge.
C. Quietly approach the client with additional staff members.
D. Administer medication to chemically restrain the client. (ANS- B
(The most important intervention is to maintain the safety of other clients by
removing them rom the proximity of the client who may potentially create a
dangerous situation)

Unformatted Attachment Preview

HESI RN MENTAL HEALTH During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative coping skills. B. Remain calm and use a matter-of-fact approach. C. Ask the client why she is so anxious D. Administer a PRN sedative to help relieve her anxiety. (ANS- A. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem? A. Acute confusion. B. Ineffective community coping C. Disturbed sensory perception. D. Self-care deficit. (ANS- A The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis? A. Tell me what you think should happen. B. How serious was the collision? C. What do you think you should do? D. Call for transportation to the hospital. (ANS- D A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit? A. Ineffective sexual patterns. B. Impaired environmental interpretation. C. Disturbed sensory perception. D. Compromised family coping. (ANS- A The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing? A. Provide detailed thorough explanations when cleansing wound. B. Perform the dressing change in a non-judgmental manner. C. Ask in a non-threatening manner why the client cut own abdomen. D. Request another staff member assist with the dressing change. (ANS- B While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique? A.Initiate a non-threatening conversation with the client. B. Dialog about the ineffectiveness of his interactions. C. Allow the client to identify the way he interacts. D. Discuss the client's feelings when he responds. (ANS- C An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? A. Meet scheduled appointment with dietitian. B. Sleep at least 6 hours a night. C. Understands the purpose of the medication regimen. D. Describes the reasons for hospitalization. (ANS- B When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? A. If your partner is abusing you, I need to ask these questions. B. State law mandates that I ask if you are a victim of domestic violence. C. The HCP provider needs to know if you are experiencing any domestic abuse. D. All clients are screened for domestic abuse because it is common in our society. (ANS- D A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? A. Unless your sister has a medical education, ignore her comments. B. I can hear that your sister comments are over-whelming you. C. Do you think it's possible that you might be a hypochondriac? D. Besides your sister's comments, what in your life is troubling you? (ANS- D The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members. B. Clarifying the nurse's role and clients' responsibilities. C. Discussing ways to use new coping skills learned. D. Helping clients identify areas of problem in their lives. (ANS- D A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from the other clients. B. Administer PRN sedative. C. Avoid recognizing the behavior. D. Escort the client to his room. (ANS- D A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg. B. Pulse rate of 68-78 BPM. C. Temperature of 99.5-99.7 F. D. Respiration rate of 24 breaths per minute. (ANS- A The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? A. Hold all bedtime medications. B. Keep the client NPO after mid-night. C. Implement elopement precautions. D. Give the client an enema at bedtime. (ANS- B A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A. Pan-seared catfish. B. Peperoni pizza. C. Deep fried shrimp. D. Beef trips with gravy. (ANS- B A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN? A. Is attempting the physically restrain the patient. B. Remains at a distance of 4 feet from the client. C. Tells the client to go to the quiet area of the unit. D. Is using a load voice to talk to the client. (ANS- A A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? A. Not sleeping for several days. B. Wishing to be with spouse. C. Lack of interest in usual activities. D. Eating very little. (ANS- A A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A. Provide education on methods to enhance sleep. B. Teach the client to develop a plan for daily structured activities. C. Suggest that the client develop a list of pleasurable activities. D. Encourage the client to exercise. (ANS- B When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping. (ANS- C A female client on a psychiatric unit is sweating profusely while she vigorously does push- ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations? A. Deficient diversional activity related to excess energy level. B. Risk for other related violence related to disruptive behavior. C. Risk for activity intolerance related to hyperactivity. D. Disturbed personal identity related to grandiosity. (ANS- B A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? A. Dim the lights in the room to help the patient feel calm. B. Sit within two feet of the client to enhance level of safety and security. C. Reduce the noise level in the room by turning off the television and radio. D. Position table between the client and the RN for extra personal space. (ANS- C An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first? A. Refer the client to the cardiology unit. B. Obtain the client Blood pressure. C. Assess the client for substance abuse. D. Determine if Xanax was taken recently. (ANS- D The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother? A. Ask the mother if she has ever thought about harming herself or her child. B. Reassure the mother that her child will achieve some growth and development milestones. C. Determine if the mother has other children who do not have developmental disabilities. D. Encourage the mother to write thoughts and feelings in journal. (ANS- A Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address? A. Medication non-compliance. B. Number of bathroom facilities. C. Infection control. D. Acting out behaviors. (ANS- C A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? A. Assure the client that all food served in the hospital is safe to eat. B. Tell the client that irrational thinking is a symptom of schizophrenia. C. Obtain an order for a tube feeding for the client. D. Provide the client with food in unopened containers. (ANS- D The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA) SELECT ALL: A. Purchase a gun to use for protection. B. Establish a code with family and friends to signify violence. C. Take a self-defense course that retaliates the abuser with injury. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit. (ANS- B, D, E The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A. Short term memory loss. B. Five pound weight gain C. Decreased affect. D. Nausea and vomiting. (ANS- D A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? A. Encourage oral fluids. B. Monitor vital signs. C. Keep the room dark. D. Apply ice to his tongue. (ANS- B A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? A. Admit to others that he is a substance abuser. B. Remain alcohol free for 12 hours prior to first dose. C. Attend monthly meetings of alcoholics anonymous. D. Completely sustain from heroin or cocaine use. (ANS- B The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement? A. Don't allow the client to go into the kitchen until the hallucination has subsided. B. Report the behavior to the client's case workers so that the family can be notified. C. Assign the UAP to remain with the client at all times. D. Document the behavior in the client's record and notify the HCP. (ANS- C A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? A. Allow the client to rest and sleep. B. Ensure client attend groups addressing coping skills for dealing with depression. C. Begin planning for the clients discharge. D. Encourage verbalization of feelings. (ANS- A Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don't believe everything my family tells you, I am not crazy. (ANS- B A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client's current feelings of depression? A. Feelings of frustration. B. A sense of loss C. Poor self-esteem. D. A lack of intimate relationships. (ANS- B The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states" I don't need to be here," and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam? A. Insight and judgement. B. Mood and affect. C. Remote memory. D. Level of concentration. (ANS- A An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? A. Explain that the feces belong in the toilet. B. Show the client how to clean the walls. C. Escort the client out of the bathroom. D. Assist the client to clean the walls. (ANS- C A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? A. Weight gain of 75 lbs. B. Thoughts of wanting to hurt himself. C. Frequent days with diarrhea. D. Alerted liver function test. (ANS- A A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority? A. Identify support systems in the community that may be helpful. B. Help the client feel safe to decrease anxiety. C. Ask the client to describe coping strategies that were helpful in the past. D. Encourage the client to verbalize anxiety related to event. (ANS- B The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation? A. A summary of the client's feelings. B. Photographs. C. A general description. D. A client's significant other's statement. (ANS- B Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? A. Prochlorperazine (Compazine) 5 mg IM. B. Hydromorphone (Dialuadid) 2 mg IM. C. Chlorpromazine (Thorazine) 50 mg IM. D. Lorazepam (Ativan) 2 mg IM. (ANS- D A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first observe (ANS- the client in the chair A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function e2ectively. What action should the nurse take (ANS- plans a list of activities to be carried out daily A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client (ANS- Do you hear voices A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home.The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take (ANS- ask client about alcohol quantity, frequency, and time of last drink Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit (ANS- i am here because the police thought i was doing something wrong A female client on a psychiatric unit is sweating profusely while she vigorously does push- ups and then runs the length of the corridor several times before crashing into the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations? (ANS- risk for other related violence related to disruptive What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks (ANS- not attempt suicide Admission A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take Blood alcohol level (ANS- ask the client about alcohol quantity, frequency, and time of last drink IPV- difficulty leaving victim of intimate partner violence what 3 things should you do (ANS- 1. establish a code with family and friends to signify violence 2. plan an escape route to use if the abuser blocks main exit 3. have a bag ready that has extra clothes for self and children Anger Management Give the client (ANS- permission to be angry The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment? (ANS- Do you frequently have temper tantrums? After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first? (ANS- assist the client out of bed and involve in activity A client with dementia uses the defense mechanism of confabulation. What is the reasoning? (ANS- to decrease anxiety A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx? (ANS- disturbed thought process A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response? (ANS- when you interrupt, i cannot explain what to do to the group When performing a MSE on a client which assessment intervention would best assist the nurse? (ANS- ask the client to interpret the proverb, "a stitch in time saves nine" A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first? (ANS- magnesium A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)? (ANS- How would you like to be involved in your husband's care? A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention? (ANS- attempt to distract the client with general conversation A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response? (ANS- you didnt do anything wrong. you have a chemical imbalance in your brain A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response? (ANS- advise the client that the nursing assisngments are not based on client requests A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism? (ANS- compulsion A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used? (ANS- repression A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do? (ANS- contact the person the client chooses to go to the home and remove the weapon A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used? (ANS- sublimation Who is most prone to being abused (elder abuse)? (ANS- Females over 75 living with their families. client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first? (ANS- go and get more staff assistance A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust? (ANSmake brief contact with the client throughout the day In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response? (ANS- redirect the client to read the handout What is the most important intervention for a client with bulimia? (ANS- plan scheduled meals A client comes into the ED with DTs. What should the nurse do first? (ANSadminister ativan What are the side effects of Resperdal? (ANS- Fever, tachycardia, and sweating. A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority? (ANS- wandering in and out of other client's rooms A nurse observes a client in the dayroom talking to himself. What should the nurse do first? (ANS- ask the client if he's currently hearing voices A client comes to the nurses' station and told the nurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next? (ANS- move the client to a private room by the nurses station A man comes into the ER after being in a car accident with an alcohol level greater than 2, what should the nurse prepare to administer? (ANS- Ativan or librium per facility policy What would be proper teaching for a client who is to start taking Antabuse? (ANShas not had anything alcoholic to drink for the last 48 hours Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do? (ANS- leave and come back 30 minutes later A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia? (ANS- delirium: started in hospital An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do? (ANS- Take the woman aside and ask about her abuse A business man is stressed about his finances, has anxiety and sleeplessness. (ANSLimit intake of sugar and caffeine A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother? (ANSConsequences of enabling behaviors What is a common side effect of cocaine use? (ANS- MI A client on LSD comes into the ER. How do you approach the client? (ANS- Talk calmly and soothing to the client A client taking Meth and Benzo's, what would the nurse prepare to do for overdose? (ANS- give narcan An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx? (ANS- Risk for injury What should you advise a patient a MAOI not to eat? (ANS- Cheese, beer, & avacado The parents of a teenager who has overdosed what is the first question to ask? (ANSWhat drug did the client ingest? A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do? (ANS- Take to quiet room and give PB crackers A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx? (ANS- Ineffective coping A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first? (ANS- Do you have a plan in place when you are not safe? SAFETY! A patient has stopped taking Depakote six months ago, what would the nurse assess? (ANS- Mood A client with Alzheimer's keeps asking for his mother. What is the nurse's appropriate response? (ANS- Your mothers not here but you are safe A client is told to come in by friends, client's complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask? (ANS- What is troubling you the most? What are the side effects of Lithium? (ANS- Dehydration, diarrhea, and thirstiness. A client with an anxiety disorder is demonstrating signs of panic. Which intervention would be the most appropriate for the nurse to implement (ANS- Decrease environmental stimuli and interaction with other people client tells the nurse that he is an accomplished writer and that directors of television shows contact him for suggestions on actors and locations. The nurse realizes this client is experiencing the delusion of (ANS- grandiosity A client tells the nurse that his father died after the client thought abut it for a few days. The nurse suspects the client is delusional and is demonstrating: (ANSmagical thinking The nurse overhears a client diagnosed with terminal cancer tell a family member that he will be discharged soon, will return to work, and plans to attend a company event scheduled in a year. The nurse realizes this client is demonstrating the defense mechanism of (ANS- denial A female client diagnosed with depression tells the nurse that her husband wants her to "fix herself up" and put on nice clothes. The client continues by saying that she believes her husband is interested in another woman. What should the nurse respond to the client? (ANS- I can help you shower and get dressed before he comes to visit A client diagnosed with schizophrenia has been refusing prescribed oral medication for several days. The client has broken chair and is coming after another client with the broken chair leg, threatening to do physical harm. What should the nurse do first? (ANS- Remove the other client from the room The nurse has identified the diagnosis imbalance Nutrition: More than body requirements for a client diagnosed with bulimia. Which intervention would be appropriate for this diagnosis? (ANS- Help client assess situations that precedes binginh A client tells the nurse that he has a fear of flying on an airplane but needs to attend a work- related meeting in another part of the country and will have to fly to get there. What can the nurse do to assist this client? (ANS- Instruct the client to visualize flying to the meeting destination During an assessment, a client from the Hispanic culture refuses to maintain eye contact with the nurse. After the nurse overhears the client say "evil eye" to a family member, the nurse realizes the client is demonstrating characteristics of which cultural-specific syndrome? (ANS- Induced by witchcraft A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression? (ANS- a sense of loss A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate (ANS- delusions of persecution A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first (ANS- ask the client to identify problems that have occurred during the last month A 26-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells her the nurse," please let me leave because the secret police are after me." Which response is best for the nurse (ANScome with me to your room and i will sit with you The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued (ANS- Benztropine (Cogentin) A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship (ANS- explore the clients feelings related to discharge A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death (ANS- become the faculty sponsor for students against drunk driving (SADD) A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test (ANS- lithium is secreted by the kidneys and creatinine is related to kidney function A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement (ANS- consult with the provider about reducing the dosage A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care (ANS- delay business decisions until his mania subsides one on one session and nurse begins to get angry at patient (ANS- terminate session patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact healthcare provider before giving (ANS- tylenol . antidepressant side effects (ANS- dry mouth, blurred vision, constipation A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take? (ANSLorazepam 8mg PO HS A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? (ANS- do not take any OTC meds The nurse documents the mental status of a female client who has been hospitalized for several days by court order, The client states, "I don't need to be here" and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? (ANS- insight and judgement depressed mother and daughter speaks in group (ANS- i hear you say you worry about your mother's distress A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? (ANS- establish trust by providing calm, safe environment When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide? (ANS- "Have the feelings associated with these events brought you to the clinic?" ECT therapy non responsive (ANS- have you taken erectile dysfunction meds adolescent teen interrupts group about pets at home (ANS- redirect him postpartum depression Sign & Symptoms (3) (ANS- distrubed sleep, sadness, poor concentration ECT (ANS- NPO after midnight health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN (ANS- pancreatitis knee surgery post op and diaphoretic and visual hallucinations (ANS- obtain VS aspiration due to caustic material related to suicide attempt (ANS- ineffective breathing pattern A 38-yea- old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make? (ANS- "ill leave your tray here. I am available if you need anything else" A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first? (ANS- explain the nurse's role to the patient A client comes out dressed in short skirt, low top, bright red lipstick. what should the nurse do? (ANS- assist back to their room and help pick out appropriate clothing A client comes in and is 5'5, 75lbs. what should the nurse do? (ANS- start an IV for IV resuscitation A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a day." What can the nurse determine from this statement? (ANS- parent is exhibiting tolerance to alcohol 2 days after admission from alcohol withdrawal what should the nurse do? (ANSmonitor HR and BP DO NOT IMPLEMENT SEIZURE PADS Something about a male client threatening a teacher or becomes upset with teacher (ANS- methods of clearly communicating *** Patient says I'm going to shoot myself" (ANS- stop client from leaving the unit History of alcoholism admitted for detoxification; 6mg of Ativan what additional prescription administer immediately (ANS- vitamin B1 (thiamine) PTSD admitted to psychiatric unit, which intervention is most important for plan of care (ANS- provide quiet room, away from rec area Chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room (ANS- may i sit with you for a while? Male client on atypical antipsychotic drug olanzapine(Zyprexa) Adverse reaction is weight gain (ANS- client sitting in corner of day room during admission assessment, what nursing action? ask client simple questions How do you take Antabuse? (ANS- each morning beginning 48 hours after your last drink of alcohol The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A. Consumption, liver enzyme, gastrointestinal complains and bleeding. B. Minimizes drinking frequently misses family events, guilt about drinking, and amount of daily intake. C. Cancer screening results, anger, gastritis, daily alcohol intake. D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener". (ANS- D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eyeopener". (Cutting down, annoyance, guilt and eye-opener drinking are represented with the acronym of CAGE) A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority? A. Place in a side-lying position with head of bed elevated. B. Administer disulfram (Atabuse ) immediately C. Give lorezapam (Ativan)PRN for signs of withdrawal. D. Provide thiamine and folate supplements as prescribed. (ANS- A (Maintain patient's airwat is the priority for a client who is intoxicated and obtunded) The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. Which medication should also be discontinued?A. Alprazolam (Xanax) B. Benztropine (Cogentin) C. Magnesium (Milk of Magneisa) D. Lithium (Lathotbabs) (ANS- B (Cogentin is given with traditional antipsychotic medications to reduce extrapyramidal side effects and should be discontinued when the antipsychotic medication is discontinued) The nurse leading a group session of adolescent clients give the members handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take? A. Give the client permission to leave and return in 10 minutes. B. Explore the client's feeling about his pets and home life. C. Encourage his peers to help involve him in the activity. D. Redirect him by encouraging him to read from the handout. (ANS- D. Redirect him by encouraging him to read from the handout. (Best nursing action is to ask the client to read from the handout) A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril) B. Offer the client a prescribed physical therapy hot pack for muscle spasms. C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. D. Direct client to occupational therapy to distract him from somactic complaints. (ANS- C (The client is experiencing a dystonic reaction due to dopamine depletion, one of the physiologic actions of Risperidone. This side effect requires immediate management with Cogentin ) A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning? A. Encourage the client to exercise. B. Suggest that the client develop a list of pleasurable activities. C. Provide education on methods to enhance sleep. D. Teach the client to develop a plan for daily structured activities. (ANS- D. Teach the client to develop a plan for daily structured activities. (Development of structure life-style is vital when a client is having difficulty with psychomotor retardation, amotivation and hypersomnia) A male client with a long history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer? A. Haloperidol (Hadol) B. Thiamine (Vitamin B1) C. Lorazapam (Ativan) D. Diphenhydramine (Benadryl) (ANS- C (A client with a history of alcohol dependency can experience delirium tremors within 72 to 96 hours after alcohol abstinence. Ativan should be given to decrease central venous systems excitation (restlessness, agitation, seizures) The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A. Completely abstain from heroin or cocaine use. B. Attend monthly meetings of alcoholic anonymous. C. Remain alcohol free for 12 hours prior to the first dose. D. Admit to others that he is a substance abuser. (ANS- C (The client must be alcohol free for 12 hours before the beginning of Antabuse therapy to avoid the precipitation of a dusulfiram reaction, an aversive effects) A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job she feels her employmemt is essential to the family's survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care? A. Relates insight into problematic relationships B. Demonstrates a healthy relationship with husband. C. Described how the family can resolve problem. D. Changes thought patterns related to problem solving. (ANS- D (Cognitive-behavior therapy focuses on changing thought pattern by directing the client to problem solving the present situation) A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A. Discuss checking the time frequently B. Ask the client why she checks the locks C. Plan a list of activities to be carried out daily. D. Determine the type and size of the locks. (ANS- C (Helps the client to gain recognition of and insight into the anxiety and assists her to learn new adaptive coping behaviors) A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. That intervention is best for the nurse to implement? A. avoid recognizing the behavior. B. Isolate the client from other clients. C. Administer a PRN sedative. D. Escort the client to his room. (ANS- D (Echolalia, constantly repeating what others are saying, can become disruptive to a community environment, so the nurse should direct the client to a private space such as his room) A young adult male is hospitallizaed due to depression and an attempted suicide attempt. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving? A. Initiates interactions with other clients. B. Describes verbally when he is angry C. Participates in a job search with a social worker. D. Denies plans to harm himself or others. (ANS- A (The best indicator of improvement in a client with depression is initiated interaction with others because such behavior indicates that the client is less withdrawn and more self-directed) The nurse is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare providers A. Body mass index of 21 B. Potassium level of 2.9 mEq/dl C. WBC of 10,000 mm3 D. Blood pressure of 110/70 mmHg. (ANS- B ( The nurse should inform the healthcare provider of potassium level of 2.9 mEq/dl, which could be caused by electrolyte imbalance) Following involvement in a motor vehicles collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures, The client's bold alcohol level is high on admission. Which PRN prescription should be administered if the client begin to exhibits signs and symptoms of delirium tremors (DT)? A. Hydromorphone (Dilaudid) 2mg IM B. Prochloperazine (Compazine) 5mg IM C. Chlopronmazine (Thorazine) 50 mg IM D. Lorazepam (Ativan) 2mg IM. (ANS- D (Ativan is often used to treat DT and of the PRN prescriptions listed, is the treatment of choice) A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take? A. Assure client that the healthcare provider will see her today. B. Recommend that the client talk with a social worker. C. Ask the client to describe why she is being stalked. D. Offer the client a safe place to relax before interviewing her. (ANS- D (The client is demonstrating fear related to an underlying metal disorder, and she needs to feel safe before anything is required of her) A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. What action should the nurse implement first? A. Administer a PRN sedative. B. Sit in the chair next to the client. C. Escort the client to his room. D. Listen to what the client is saying. (ANS- D (Auditory hallucination can have various meanings to the client. Listening to what the client is saying helps the nurse determine the type of response that is required based on the hallucinatory messages the client is receiving) A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care? A. Initiate caloric and nutritional therapy. B. Implement behavioral modification therapy. C. Evaluate the client for low self-esteem. D. Record daily weights and graft trend. (ANS- A (The client presents with evidence of anorexia nervosa resulting from self-starvation, which is a life-threatening condition. Providing nutrition and calories is the priority intervention so that the risk of electrolyte imbalance and severed dehydration can be reduced) The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? A. Opportunities to contribute to one's treatment plan. B. One on one dialogue sessions with the therapist. C. Regularly scheduled unit activities for peer interaction. D. Home visits to reintergrate into the family. (ANS- C (The nurse is responsible for maintaining a therapeutic milieu which provides a secire and structure environment that promotes client's safety, provide opportunities for the client to learn healthy coping skills) After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. What action should the nurse take? A. Recommend assignment to the receptionist's office. B. Suggest that the student work in the athletic department. C. Refer the student to a psychiatrist for further discussion. D. Determine the parent's opinion of the work assignment (ANS- A (Client with anorexia are obsessed with food and exercise, which often trigger self indulgence. Assignment to the receptionist's office decreases the opportunity for the student to be distracted with obsession associated with anorexia) A middle-aged remale client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse "I want to find out why these people are stalking me" which response should the nurse provide? A. "It sounds like this experience is frightening for you" B. "What makes you think people are stalking you?' C. "I know you are frightened, but no one is stalking you" D. "Do you think someone is trying to harm you" (ANS- A (The nurse should respond to the client's fear without addressing the delusion.) A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client's family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority? A. Administer paraxeitne 40 mg as prescribed. B. Develop a list of therapy programs. C. Remove all shaving equipment. D. Determine if client has a suicide plan. (ANS- C (Keeping the client safe is priority, so suicide precautions should be implemented, C is priority) A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?A. Offer to play a game of cards with the client. B. Report the behavior to the next shift. C. Document the behavior in the chart. D. Plan to talk with the client the next day. (ANS- A (Playing a game with the adolescent will establish rapport because adolescent usually communicate more easily if involve in an activity) Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit. A. " I am here because the police thought I as doing something wrong" B. "At least I hit the wall instead of hitting the psychiatric aide" C. "I want to be here because I know it is the best psychiatric facility" D. "Don't believe everything my family tells you, I am not crazy" (ANS- A (Blaming others for unacceptable desires, thought, shortcomings or mistakes is using the defense mechanism of projection) A female high school teacher who was a child alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which client behavior is the best indicator that the client is coping well with anxiety related to the student's dealth? A. Signs a safety contract with the nurse agreeing not to hurt herself or others B. Confront her parents about the hurt she felt as achild of alcoholic parents. C. Becomes the faculty sponsor for Student Against Drunk Driving (SADD) D. Describes alternatives to becoming depressed over the student's death. (ANS- C (C is a method if channeling anxiety and denotes an adaptive behavior to a crisis situation) While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The nurses' ability to directly observe the client's non verbal communication is limited with note takes B. Taking notes during an interview is a legal obligation of the examining nurse. C. The client's comfort level is increased when the nurse breaks eye contact to take note to take note. D. The interview process is enhanced with note taking and allows the client speak at normal pace. (ANS- A (Although note-taking is important, particularly when a detailed report is vital to the assessment, note-taking requires a break in eye contact and impedes the nurse's observation of the client's nonverbal behavior) An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite. B. The emotional quality of his attitude C. His level of activity. D. The interactions he has with others. (ANS- B (The most important assessment is related to mood or the emotional quality of his attitude so the nurse should assess for the presence of depressed mood and suicide ideation) While setting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques? A. Discuss the client's feeling when he responds. B. Allow the client to identify the way he interacts. C. Initiate a non-threatening conversation with the client. D. Dialog about the ineffectiveness of his interactions. (ANS- B (The nurse is using role-playing to help the client identify his behavior when interacting with others, B which provides an opportunity for the client to rehearse assertive interactions) A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A. Transport of the client to the seclusion room. B. Take other clients in the area to the client lounge. C. Quietly approach the client with additional staff members. D. Administer medication to chemically restrain the client. (ANS- B (The most important intervention is to maintain the safety of other clients by removing them rom the proximity of the client who may potentially create a dangerous situation) Name: Description: ...
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.
Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4