NP5

What is the definition of mental health by the World Health Organization (WHO)?

A. It a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

 

B. It is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn and work well, and contribute to their community.

C. It is the process of enabling people to increase control over, and to improve, their health.

D. It is the autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people

A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?

A. Frontal Lobe

B. Temporal Lobe

C. Parietal Lobe

 

D. Occipital Lobe

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 

A.Paranoid thought process

B. Rapid heartbeat or anxiety

C. Alcohol withdrawal symptoms

 

D. Thought broadcasting or delusions

A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate non-compliance with this medication?

A. Complaints of insomnia

B. Complaints of weight gain

 

C. A pulse rate of less than 60 beats per minute

D. Frequent handwashing with hot, soapy water

Prenatal client has been told during a primary health care provider office visit that testing is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?

A. Pain

B. Nonadherence

C. Anticipatory grieving

D. High risk for infection

A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, “What have I done to cause this? If only I could live my life over.” Considering this statement, which concern would the nurse identify for the client?

A. Injury to the fetus because of maternal distress

B. Low self-esteem because of pregnancy complications

C. Lack of understanding about diabetic self-care during pregnancy

 

D. Poorly perceived body image caused by complications of pregnancy

A client diagnosed with myasthenia gravis is ready to return home. The client confides about being concerned that the partner will no longer find the client physically attractive. Which client-focused action would the nurse encourage in the plan of care?

A. Attend a support group.

B. Cease dwelling on the negative.

C. Reach out for help to face this fear.

 

D. Share feelings with the partner.

The parents of a newborn infant diagnosed with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which concern for the parents?

A. Inability to cope with change

B. Anger about lost opportunities

C. Trouble adjusting to a child born with medical issues

 

D. Depression associated with the birth of a child with defects

A client with a diagnosis of schizophrenia and psychosis is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and the client’s affect is belligerent. Which priority nursing intervention based on these objective data would the nurse implement?

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

B. Bring the client to a less stimulated area to regain control.

 

C. Provide the clients on the unit with a sense of comfort and safety.

D. Assist the staff in caring for the client in a controlled environment

A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction would the nurse provide?

A. Avoid prolonged exposure to the sun.

B. Adhere to a strict tyramine-restricted diet.

 

C. Recognize the signs and symptoms of a relapse of depression.

D. Have therapeutic blood levels drawn because the medication has a narrow therapeutic range.

The parent of a teenage client diagnosed with an anxiety disorder is concerned about the teenager’s progress after discharge. The parent states that the teenager “stashes food, eats all the wrong things that causes hyperactivity,” and “hangs out with the wrong crowd.” To assist the parent with preparing for the teenager’s discharge, the nurse advises the parent to implement which action in order to promote optimal health?

A. Restrict the teenager’s socializing time with school friends.

B. Consider taking time off to help the teenager readjust to the home environment.

 

C. Limit the amount of chocolate and caffeine products that are available in the home.

D. Keep the teenager out of school until the teenager can prove the ability to adjust to the school environment.

Which event would the nurse identify as a situational crisis?

A. Retirement

B. Loss of a job

C. An earthquake

 

D. The birth of a child

Which explanation by the nurse would best alleviate anxiety in a client with coronary artery disease about having a 12-lead electrocardiogram (ECG) diagnostic procedure?

A. “It’s a simple test, but it’s important to lie still during the procedure.”

B. “It should only take about 20 minutes to complete the ECG tracing process.”

C. “The ECG electrodes are painless and will record the electrical activity of your heart.”

D. “The ECG can give the primary health care provider information about the status of your heart.”

A client experiencing a major depressive episode is unable to address activities of daily living (ADLs). Which nursing intervention best meets the client’s current needs therapeutically?

A. Have the client’s peers approach the client about how noncompliance in addressing ADLs affects the milieu.

B. Structure the client’s day so that adequate time can be devoted to client’s assuming responsibility for ADLs.

 

C. Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining one’s own ADLs.

D. Feed, bathe, and dress the client as needed until the client’s condition improves so that these activities can be performed independently.

A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of depression and abusing the selective serotonin reuptake inhibitor, sertraline. The nurse would immediately conduct which assessment?

A. Pulse

 

B. Respirations

C. Blood pressure

D. Urinary output

The nurse monitors the client taking amitriptyline for which common side effect of this antidepressant?

A. Diarrhea

B. Drowsiness

C. Hypertension

 

D. Increased salivation

The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention would the nurse incorporate into the nursing care plan to best ensure client safety?

A. Check the client’s location every 15 minutes.

B. Begin suicide precautions with 30-minute checks.

C. Initiate one-to-one suicide precautions immediately.

D. Ask the client to report suicidal thoughts immediately.

The nurse is planning care for a client admitted with suicidal ideations. To best ensure client safety the nurse would implement additional precautions during which time period?

A. During the day shift

B. On weekday evenings

C. Between 0800 and 1000

D. During the unit shift change

A client is admitted to the psychiatric unit after a suicide attempt. The nurse would plan which intervention as the most important to maintain client safety?

A. Assigning a staff member to remain with the client at all times

B. Requesting that the client promise to alert staff of suicidal thoughts

 

C. Removing the client’s personal clothing and replacing them with a hospital gown

D. Placing the client in a seclusion room where all dangerous articles are removed

A client with a history of depression will be participating in cognitive therapy for health maintenance. The client asks the nurse, “How does this treatment work?” Which statement is most appropriate for the nurse to make to the client?

A. “This treatment helps you relax and develop new coping skills.”

 

B. “This treatment helps you confront your fears by gradually exposing you to them.”

C. “This treatment helps you examine how your past life has contributed to your problems.”

D. “This treatment helps examine how your thoughts and feelings contribute to your difficulties.”

A client with the diagnosis of mania emerges from the room topless while making sexual remarks and lewd gestures toward the staff and peers. Which action would the nurse take first?

A. Quietly approach client and escort to own room to get dressed.

B. Confront client on the inappropriateness of the behavior and offer client a time out.

 

C. Ask other clients to ignore the behavior; eventually client will return to their own room.

D. Approach client in the hallway and insist that client go to their own room immediately.

The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client’s beliefs?

A. Is accepting of body size

B. Views purging as an accepted behavior

C. Overeats for the enjoyment of eating food

D. Gorges in response to losing control of diet

The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?

A. “When I get stressed out about school, I just like to be alone.”

 

B. “I find myself very moody. I’m happy one minute and crying the next.”

C. “I don’t eat any fatty foods, and I’ve already lost 8 pounds in 2 weeks.”

D. “I can’t seem to wake up in the morning. I would sleep until noon if I could.”

The nurse is caring for a hospitalized 14-year-old adolescent client who is placed in Crutchfield traction. The adolescent is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the adolescent’s needs?

A. Allow the adolescent to play loud music in the hospital room.

B. Let the adolescent wear their own clothing when friends visit.

C. Allow the adolescent to have their hair dyed if the parent agrees.

 

D. Allow the adolescent to keep the shades closed and the room darkened.

During the assessment, the nurse notes that the child’s genitals are swollen. The nurse suspects that the child is being sexually abused. Which priority action would the nurse take?

A. Document the child’s physical findings.

 

B. Report the case because abuse is suspected.

C. Refer the family to appropriate support groups.

D. Assist the family with identifying resources and support systems.

The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention would be included in the nursing care plan?

A. Placing the client in a private room to ensure privacy and confidentiality

B. Interacting with the client demonstrating examples of unconditional positive regard

C. Maintaining a distance of 10 inches to assure client that personal control will be provided

 

D. Placing the client in charge of a meaningful unit activity, such as the morning chess tournament

The nurse cared for a client who died a few minutes ago. Which event supports the nurse’s belief that the client died with dignity?

A. The family thanks the nurse for facilitating such a peaceful death.

B. The nurse states that it is difficult to give that kind of care to a dying client.

C. The physician acknowledges that all of the prescriptions were carried out.

D. The nurse kept the client’s last hours comfortable with increasing doses of pain medication.

A client who is to undergo thoracentesis is afraid of not being able to tolerate the procedure. The nurse interprets that the client needs honest support and reassurance that is best accomplished with which information?

A. “I’ll be right by your side, but the procedure will be totally painless as long as you don’t move.”

B. “The procedure only takes 1 to 2 minutes, so you might try to get through it by mentally counting up to 120.”

C. “The needle hurts when it goes in, and you must remain still. I’ll stay with you throughout the entire procedure and help you hold your position.”

D. “The needle is a little bit uncomfortable going in, but this is controlled by rhythmically breathing in and out. I’ll be with you to coach your breathing.”

A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication would the nurse determine may be the best for the client?

A. Use a picture or word board.

B. Have the family interpret needs.

C. Devise a system of hand signals.

D. Use a pad of paper and a pencil.