Mental Health Final

Sexual assault examiner is caring for a client who experienced sexual assault which of the following acts should the nurse take

protect the client from further harm

A nurse is speaking with a client who experienced physical assault which of the following should the nurse take

allow the client to control the conversation

A nurse is caring for a client who has been admitted for psychiatric evaluation after displaying aggressive behaviors toward their partner and two-year-old child which of the following statements should the nurse identify as contributing to aggression?

my parent used their fist to hit me as a child

A nurse is caring for a client who is having trouble managing anger and is it upset they feel their property is being disrespected which of the following statement should the nurse recognize as the cause of client’s  anger and frustration?

my neighbor has been letting their dog come into my yard every day to dig holes, bury bones and go to the bathroom

A nurse is assessing a client who is experiencing grief. The nurse should identify which of the following findings as an indication that the client has developed clinical depression.

a loss of interest in pleasurable activities

A charge nurse is observing a newly hired nurse provide grief informed care for a client which of the following actions by the newly hired nurse requires, followed up by the charge nurse

the nurse asked the client why they require care or assistance

A nurse is caring for an adolescent client, whose friend recently died by suicide. The client tells the nurse I should have called back when they text me if I had been there, my friend would still be alive which of the following information show the nurse understand from the statement.

this is an expression of emotional pain, and the client needs to be closely monitored

A nurse is teaching another nurse about Freud’s cycle analytic theory related to human behavior which of the following statements regarding the Id should the nurse include in the teaching.

the Id is often an area used for instant gratification

A nurse is planning to teach a client about behavioral therapy. Which of the following statement should the nurse plan to include

behavioral therapy is a type of psychotherapy that helps you modify maladaptive behavior patterns

A nurse is reviewing the physical environment of a child and patient unit, which of the following contradicts Milieu therapy?

a craft room with scissors and other art supplies

A nurse is caring for a group of clients in mental health. The nurse should identify that which of the following clients is exhibiting warning signs of suicide.

a client who is giving away their possessions

A nurse is discussing the difference between mental health and mental illness with a newly licensed nurse, which of the following statements by the newly licensed nurse indicates the understanding?

mental illness is when there is a disruption in a person‘s ability to complete activities of daily living whereas mental health is when the person can cope with daily stressors

A nurse in the long-term care facility noticed two residents arguing in the day room over a game they are playing. Which of the following interventions should the nurse use first?

Distract the clients by asking them to participate in an activity

A nurse is caring for an elder adult client who has dementia the client’s family. Member asked why the provider will not prescribe a medication to calm the client down, which of the following statement to the nurse make? 

it can increase their risk for falls

A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

restrict your child’s and take up caffeine while she is taking this medication

A nurse is caring for a client who is depressed and refuses to participate in group therapy and activities of daily living. Which of the following should the nurse make to the client?

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

A nurse is caring for a client with schizophrenia, which of the statements by the client indicates understanding of relapse prevention plan?

 I know which of my hallucinations trigger my relapse

A nurse is discussing the therapeutic MILIEU with a newly licensed nurse, which of the following statements by the newly licensed nurse indicate understanding of therapeutic MILIEU?

the MILIEU consist of the physical and psychosocial environmental factors

A nurse notes that the colleague seems exhausted, discouraged, distracted, and expressed dissatisfaction of being a nurse. The nurse should identify these manifestations of which of the following conditions?

burnout

A nurse and substance rehab facility is preparing a client for discharge the client states my landlord will not allow me to continue staying in my apartment because of my prior drug use. I have no place to live. Which of the following statements.

I will contact a social worker to set up housing for you

Which feature should be present in a therapeutic MILIEU for a client experience hallucinogen overdose?

Simple and safe

Which goal for treatment of alcohol use disorder of the nurse address?

achieve physiological stability

A nurse cares for a diagnosis of paraphilia. The nurse expects the healthcare provider may prescribe, which of the following medication’s to reduce paraphilia behaviors.

Mood stabilizers

A nurse assesses for clients between the ages of 70 and 80, which clients has the highest risk of alcohol abuse? 

the client who began drinking alcohol daily after retirement and says a few drinks keeps my mind off of arthritis

A nurse as a mental health center prepares administration a scheduled injection of haldol to a patient diagnosed with schizophrenia. As the nurse swaps the site, the patient shall stop. I don’t want to take the medication anymore. I hate the side effects. What is the best action of the nurse?

stop the medication administration procedure, and say to the patient. Tell me more about the side effects you’ve been having.

A nurse assesses an inpatient psychiatric unit notices that exits are free from obstruction. No one is smoking. The janitor closet is locked and all sharps objects are being used under staff supervision. The observation relate to which nursing responsibility?

Management of milieu safety

A newly admitted patient who is acutely psychotic and a private patient of a senior psychiatrist to whom does the psychiatric nurse who is assigned to the patient of the duty of care?

The patient

Which individual diagnosed with mental illness, may need emergency and involuntary hospitalizations for mental illness?

the patient who throws a heavy plate at a waiter at the direction of command hallucinations

A client with experiencing panic which nursing intervention should be implemented first?

Provide calm, brief directive communication

A patient at an emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all the questions. The patient avoids eye contact, and has a sad affect slump shoulders. Assessment of which additional problem has priority. 

Risk of intimate partner violence

An employee has recently been absent from work for several occasions each time the employee returns wearing dark sunglasses they show and body bruises are apparent during the occupational health nurse interview. The employee says my partner beat me, which should the nurse next action be? 

Assess and document injuries with a body map

A patient diagnosed with mental illness as this psychiatric technician what’s the matter with me the technician replies your wingnuts need tightened. The nurse who overheard the exchange should take action based on what principal?

violation of the patient’s rights. Client should be treated with dignity and respect

A nurse visits the home of an 11-year-old child and finds that the child caring for three younger siblings. Both parents are at work. The child says I want to go to school, but we can’t afford a babysitter. What preliminary assessment is evident.

child and sibling are experiencing neglect

The spouse of a patient who experiences delusions as the nurse are there any circumstances under which the treatment team is justified and violating the patient’s right to confidentiality? What is the nurse’s best response. 

we are not bound if the patient threatens the life of another person

A nurse is caring for a nine-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part and physical activities at school, which of the following responses should the nurse make?

tell me more about how you are feeling about your son‘s activities

A charge nurse is providing teaching to a staff nurse who is assisting the provider with ECT, electroconvulsive therapy which of the following responses by the staff nurse indicates understanding of teaching? 

informed consent should be obtained prior to ECT

A home healthcare nurse is caring for older client who tells the nurse she’s feeling tired and unable to shop for groceries and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurses job which of the following is appropriate nursing response? 

let’s look at some other resources to solve your problem

A client who is about to undergo abdominal surgery stay steady. He is very anxious about the operation. Which of the following responses. Should the nurse make?

ask him to describe what he is feeling

A nurse is in an acute mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse. I’m being captain in prison against my own. Will please try and get me out what is the best response from the nurse?

you feel that you don’t belong here?

 nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities and participate in the units programs. Which of the following response to the nurse make?

I will help you get ready and then you can rest after activities

A nurse is caring for a client who asked the nurse may I please have your home address so that I can send you a note after I get home which of the following is the best response from the nurse?

thank you for the kind words unfortunately I’m not allowed to share my home address by policy of the hospital

A nurse is caring for a client who is refusing to attend group therapy. The client states I don’t know why you think I need therapy. I am fine without it which of the following responses by the nurse indicate a therapeutic response?

you don’t feel like group therapy is for you, tell me more about what you know about group therapy

A nurse is talking with a guardian of a school-age child recently diagnosed with intermittent explosive disorder IED. The guardian says my child is impulsive acts out aggressively and seems pleased with themselves. How can my child be happy? Which of the following responses to the nurse make?

appearing pleased after an aggressive or impulsive act can be a sense of relief rather than being happy

A nurse is assessing a new admitted client who states that they do not want to live alone anymore and plan to end their life which of the following action should the nurse take?

ask the client about the lethality of their plan

A nurse on the inpatient mental health unit is caring for a client who has admitted with suicidal ideation, which of the following statements by the client should the nurse identify as a continuation of suicidal ideation? 

I’m going to give my sister my poetry collection when I get home

A nurse is caring for a client who has depression which of the following non-invasive treatment should the nurse recommend to the client?

cognitive behavioral therapy

A nurse is caring for a client who is experiencing periods of hyperactivity impulsivity, and inattentiveness which of the following medication should the nurse anticipate the provider prescribe? 

Central Nervous System Stimulant

A nurse is caring for a client who is experiencing delusions, hallucinations, and alteration, and speech which of the following medication for the nurse anticipate the provider to prescribe?

1st generation antipsychotics

A nurse is caring for a client who has been prescribed clozapine which of the following topics should the nurse prepare to discuss with a client?

the importance of medication adherence after the resolution of acute psychosis, when taking an antipsychotic

A nurse is caring for a client who is experiencing abuse. The client says it was my fault. I made my partner upset. The nurse should identify that the client is demonstrating which of the following manifestations?

guilt

A nurse is discussing mental health with a client, which of the following statements by the client requires nurse follow up?

on the weekends when my kids are with their other parent I often just lay in bed all day and cry because I feel hopeless

A nurse is admitting a new client to the unit which of the following action. Should the nurse take to build a report with a client?

remain silent after asking the client a question to allow the client a chance to respond

Nurse has described the behavioral health unit being based on MILIEU therapy to a client. The client ask, how is a unit which has MILIEU therapy different from other hospital units? Which of the following responses should the nurse make?

a mental health unit which includes MILIEU therapy, ensures every aspect of care intentionally focused on creating a safe and therapeutic environment

A nurse is caring for a client who has major depressive disorder. Which of the following findings. Should the nurse expect?

sleep disturbances

A nurse and an emergency department is caring for a client who is experiencing alcohol withdrawal which of the following actions to the nurse take first?

perform a neurological exam

A nurse is caring for a client who has major depressive disorder, MD which of the following the nurse expect?

significant change and weight

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

inspect the clients personal belongings

A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge?

 I will take my medicines as I should and know to call the number you gave me if I have bad thoughts

A nurse is caring for a client who is experiencing manic episode. Our clients begin to complain about her disruptive behavior on the unit. Which of the following actions to the nurse take?

set limits on the client’s behavior and be consistent in approach

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following response to the nurse make first?

What are the voices telling you?

A nurse is assessing a client who reports an increase in anxiety, which of the following responses to the nurse make?

tell me what has been happening lately

A nurse is caring for a client who has major depressive disorder and has prescribed CITALOPRAM two weeks ago with a planned dose increase one week ago the client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions to the nurse take?

explain that antidepressants often takes several weeks to fully be effective

A nurse is reviewing the medical histories of four clients which of the following clients may develop extrapyramidal symptoms EPS from medication therapy?

a client who has schizophrenia is taking anti-psychotic medication

A nursing manager on a mental health unit is discussing involuntary admission during a staff meeting. Which of the following statements should the manager include in the discussion?

clients who are involuntary admitted to have the right to inform consent

Which is the most therapeutic characteristics for a nurse working with a client beginning treatment for alcohol addiction to present?

empathetic, supportive

When a client first began using alcohol, two drinks produced relaxation and drowsiness. After one year four drinks are needed to achieve the same response. Why has the change occurred?

tolerance has developed

An adult says when I was a child I took medication because I could not follow my teachers direction. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty at my job which disorder is most likely?

ADHD

A patient tells the nurse my sexual functioning is normal when my partner wears lace without it. I’m not interested in sex. The comment indicates which sexual disorder?

fetishism

An elderly client must be physically restrained. Who is responsible for the client safety.

the nurse assigned to care for the patient

A patient is hospitalized for a major depressive disorder. A nurse can expect to likely provide the patient with teaching about the medication? 

fluoxetine

The nurse will order a special diet for the patient taking the medication?

PHENELZINE

A nurse assessing a newly admitted, patient diagnosed with major depressive disorder. Which statement is an example of attending?

I’d like to sit with you for a while, so you may feel more comfortable talking to me

The following patients are seeing in the emergency department. The psychiatric unit has one bed available. The patient demonstrating which problem should the admitting officer recommend for admission to the hospital?

has begun hearing voices, encouraging her to smother your infant

A suspicious and socially isolated patient lives alone, eats one meal a day and is nearby shelter and spends the remaining day food allowance on cigarettes. Select the community psychiatric nurse best initial action.

assist the patient’s weight determine the food and amount eaten

A participant at a community education conference ask what is the most prevalent type of mental disorder in the United States? What is the nurse’s best response?

anxiety disorders

A 79 year-old adult nurse I feel very sad lately. I do not have much to live for. My family and friends are all dead and my own health is failing. The nurse should analyze this comment as suggestive as what?

evidence of suicide

Police bring a client to the emergency department after automobile accident. The client demonstrates poor coordination slurred speech but the vital signs are normal. The blood alcohol level is 300 mg port doses a liter. Consider considering the relationship between the assessment findings and the blood alcohol level which conclusion is more probable?

the client has a high tolerance to alcohol

Which patient statement does not identify qualities of nursing practice with high therapeutic value?

my nurse is willing to go to social activities with me

A nurse is caring for adolescent client who has a new diagnosis of schizophrenia. The client’s are tearful and expressed feelings of guilt. Which of the following statements should the nurse make?

you said that you feel guilty about your daughter’s diagnosis let’s talk about what is causing you to feel this way

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include in the plan? 

talk the client through task one step at a time