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Terms in this set (155)A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: 1. echolalia an idea of reference A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?: 1. echolalia waxy flexibility The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?: 1. auditory hallucinations poor personal hygiene A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question: 1. "How long has the voice been directing your behavior?" "What is the voice telling you to do?" A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?: 1. powerlessness risk for suicide A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?: 1. "Are you having thoughts of suicide?" "Are you having thoughts of suicide?" A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply: 1. imbalanced nutrition: more than body requirements disturbed thought processes sleep deprivation The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply: 1. touch the patient to provide reassurance provide a structured environment for the patient ensure that the patient's nutritional needs are met The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply: 1.
channeling excessive energy instilling a sense of hopefulness assisting with self-care activities accommodating psychomotor retardation Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply: 1. maintain arm's-length, one-on-one direct observation at all times maintain arm's-length, one-on-one direct observation at all times check all items brought by visitors and remove risk items use plastic eating utensils; count utensils upon collection manic depression = bipolar A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?: 1. discourage rest periods during the daytime ANSWER: RATIONALE: A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?: 1. temporary memory loss is the most common adverse effect of ECT temporary memory loss is the most common adverse effect of ECT A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?: 1. encouraging decision-making ANSWER: RATIONALE: A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?: 1. "You really need to follow the rules of the unit and get out of bed." ANSWER: RATIONALE: A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?: 1. sit with the client and offer simple, direct information sit with the client and offer simple, direct information A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for Buproprion. Which of the following statements by the client indicates understanding of the teaching?: 1. "I may develop a slow heartbeat while taking
Bupropion." "I may not notice a lifting of my mood for at least 2 weeks." A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation?: 1. "I had a great trip to the Smokey Mountains." ANSWER: RATIONALE: A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm really feeling down and don't want to talk to anyone right now." Which of the following responses should the nurse make?: 1. "It might help you feel better if you talk about it." ANSWER: RATIONALE: A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?: 1. "Everyone feels better after showering." ANSWER:
RATIONALE: A nurse in an acute mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?: 1. encourage family to take the client out of the facility for short periods of time ANSWER: RATIONALE: A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?: 1. ask the client if she has a plan to commit suicide ANSWER: RATIONALE: A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates an understanding of the teaching?: 1. "I need to make a voluntary choice to stop feeling depressed." ANSWER: RATIONALE: A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?: 1. being married chronic illness A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply): 1. request an ECG -request an ECG (a baseline ECG allows the provider to identify cardiac changes that can occur during ECT) -witness the informed consent (required prior to ECT unless the client is receiving involuntary treatment) -check the client's blood pressure (a baseline blood pressure allows the provider and nurse identify cardiac stress that can occur during ECT) A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?: 1. a semi-private room across from the day room ANSWER: RATIONALE: A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting?: 1. flight of ideas grandiosity flight of ideas = refers to continuous, rapid speech which abruptly changes from topic to topic grandiosity = refers to the client's belief that he has special abilities or great powers reality testing = refers to the client's ability to recognize and correct alterations in thinking derealization = refers to the client's belief that the environment is unreal or distant A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?: 1. provide a stimulating environment
have consistent unit routines A nurse in an acute mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?: 1. the client has begun playing basketball with several other clients during the past month ANSWER: RATIONALE: A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?: 1. Fluvastatin ANSWER: RATIONALE: A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply). 1. Paroxetine -Paroxetine (antidepressant/SSRI) -Lithium (used to treat mania and depression) -Valproate (anticonvulsant/mood stabilizer) -Carbamazepine (anticonvulsant/mood stabilizer) A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?: 1. "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." ANSWER: RATIONALE: A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?: 1. reviewing the client's toxicology laboratory report ANSWER: RATIONALE: A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply): 1. death of a parent at a young age -death of a parent at a young age -recent or impending move -low parental expectations -sudden decline in school performance A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station sat 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?: 1. "You are being unreasonable, and I will not call your doctor at this hour." "You must be very upset about something." A nurse is caring for a client who has bipolar disorder and is taking Lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?: 1. withhold the medication ANSWER: RATIONALE: A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?: 1. "His favorite teacher committed suicide a few weeks ago." ANSWER: RATIONALE: A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?: 1. watching a video with a group in the day room ANSWER: RATIONALE: A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?: 1. implement the client's behavioral modification plan ANSWER: RATIONALE: A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?: 1. place metal utensils on the client's metal tray inspect the client's personal belongings A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?: 1. the client's spouse reports that the client has recently gained weight ANSWER: RATIONALE: A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for Lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause Lithium toxicity?: 1. experiencing diarrhea experiencing diarrhea A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?: 1. a private room in a quiet location on the unit ANSWER: RATIONALE: A nurse is caring for a client who has bipolar disorder. Which of the following actions by the nurse should the nurse interpret as displaying manic behavior? (Select all that apply): 1. talking in rapid, continuous speech -talking in rapid, continuous speech -interacting with others in a flirtatious way -spending large sums of money A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide?: 1. substance use disorder -substance use disorder -age greater than 45 years old -schizophrenia A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?: 1. "You have a great deal to live for." "You've been feeling that your life has no meaning." A nurse is caring for a client who has bipolar disorder and a new prescription for Valproate. Which of the following instructions should the nurse give the client about the use of this medication?: 1. thyroid function tests should be performed every 6 months ANSWER: RATIONALE: A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?: 1. turn on a dance video so the client can burn off excess energy ANSWER: RATIONALE: A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply): 1. "I exercise aerobically three times a day for 30 minutes at a
time." -"I get 7 hours of sleep at night by skipping afternoon naps." -"I think about being on my favorite beach vacation when I get anxious." -"I tense and release my muscles, starting with my feet." -"I see the glass as half-full when it starts looking empty." A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?: 1. "Do you think your anxiety is worse than everyone else's?" "Tell me what has been happening lately." A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?: 1. "I plan to sit on a park bench for a few minutes each day." ANSWER: RATIONALE: A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?: 1. reaction-formation ANSWER: RATIONALE: A nurse in a mental health clinic is assessing a client who was brought by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?: 1. xenophobia ANSWER: RATIONALE: A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?: 1. "It sounds like you're having a difficult time." ANSWER: RATIONALE: A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan?: 1. contact the crisis counselor once a week ANSWER: RATIONALE: A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?: 1.
attention-seeking conduct ANSWER: RATIONALE: A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?: 1. dissociation ANSWER: RATIONALE: A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply): 1. avoid eye contact to prevent escalation of anxiety -establish rapport with the client -identify the cause of the anxiety -validate the client's feelings A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?: 1. instruct the client to sit down and stop pacing walk with the client at a gradually slower pace A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?: 1. conversion ANSWER: RATIONALE: A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?: 1.
protecting the client from injury protecting the client from injury A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?: 1. "Most clients with anxiety issues benefit from lying down." ANSWER: RATIONALE: A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?: 1. limit the amount of time available to interact with others ANSWER: RATIONALE: A nurse is caring for a client who has generalized anxiety disorder and is taking Buspirone. Which of the following adverse effects should the nurse report to the provider?: 1. sweating ANSWER: RATIONALE: A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?: 1. suggest that the client rest in bed ANSWER: RATIONALE: A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for Alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering Alprazolam?: 1. the client states, "I see purple bugs crawling on the wall" ANSWER: RATIONALE: A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?: 1. remain with the client ANSWER: RATIONALE: A nurse interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. The nurse should ask which of the following questions to determine the patient's ability to cope with this situation?: 1. "Don't you think you'll get through this in time?" ANSWER: RATIONALE: A nurse is caring for a patient who gave birth to a stillborn baby. Which of the following is an appropriate statement by the nurse?: 1. "You probably want to hold your baby." ANSWER: RATIONALE: A nurse on a med-surg unit is assessing a patient who sustained injuries 12 hrs ago following a motor-vehicle crasu. The blood alcohol level was 325 mg/dL. Which of the following findings indicate the client is experiencing alcohol withdrawal?: 1. somnolence ANSWER: RATIONALE: A nurse is teaching a family member and a client who has a new diagnosis of Azheimer's disease and is to start taking Donepezil. Which of the following statements is to be included in the teaching?: 1. "Take this medication in the evening at bedtime." ANSWER: RATIONALE: A nurse is discussing a 12-step program with a patient who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information is to be included in the teaching?: 1. the program will help the client accept responsibility for his disorder ANSWER: RATIONALE: During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions is an appropriate action for the nurse to take?: 1. ask the client to identify the bomb in her room ANSWER: RATIONALE: A nurse is admitting a client with major depression disorder and a NEW prescription for Tranylcypromine. Which OTC med that the patient reports taking should alert the nurse to a potential adverse reaction?: 1. Lansoprazole Phenylephrine A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?: 1. delusions anhedonia A nurse in an ED department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by her mother acknowledges the daughter's diagnosis?: 1. "She works so hard at ballet. Will she still be able to perform." ANSWER: RATIONALE: A nurse is assessing a patient who has major depressive disorder and has been receiving Amitriptyline for 1 week. Which of the following should the nurse expect?: 1. rapid improvement in affect within 30-60 mins after taking the
medication ANSWER: RATIONALE: A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following should the nurse include?: 1. repeatedly talks about the traumatic incident ANSWER: RATIONALE: A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?: 1. weight loss 10% of total body weight in 3 months ANSWER: RATIONALE: A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?: 1. Diazepam 5 mg IV bolus ANSWER: RATIONALE: A client who has a diagnosis of depression is attending a group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. The patient does not respond when it is her turn. What is an appropriate action by the nurse before repeating the request to the patient?: 1. allow the client time to collect her thoughts
ANSWER: RATIONALE: A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?: 1. call the provider to obtain an immediate prescription for restraint ANSWER: RATIONALE: A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following teaching should the nurse include?: 1. have a family member present during treatment ANSWER: RATIONALE: A client who has bipolar disorder is to be discharged home with a prescription for Lithium. Which statement indicates that the client has received effective teaching?: 1. "I should eat a regular diet with normal amounts of salts and fluids." ANSWER: RATIONALE: A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?: 1. allowing a client to choose which unit activities to attend ANSWER: RATIONALE: A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take?: 1. encourage the parents to avoid discussing the death with their
other children to protect their feelings ANSWER: RATIONALE: A nurse in a mental health clinic is planning care for a client who has a new prescription for Olanzapine. Which of the following interventions should the nurse identify as the priority?: 1. advise the client to take frequent sips of water ANSWER: RATIONALE: A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse indicate? (Select all that apply): 1. occupational therapy -occupational therapy -meal delivery services -physical therapy -home health services A nurse is reviewing laboratory results for a client who has schizophrenia and is taking Clozapine. Which of the following values should the nurse identify as a contraindication for this medication?: 1. WBC 2,500/mm3 ANSWER: RATIONALE: A nurse in an outpatient mental health setting is collecting a health history from a patient who is taking Paroxetine for depression. The patient is also taking herbal supplements. Which supplement has an adverse interaction with Paroxetine?: 1. St. John's wort ANSWER: RATIONALE: A nurse is teaching a newly licensed nurse about nursing care plans for patients who have depressive disorders. Which of the following statements indicate an understanding of the teaching?: 1. "I will use the same plan of care and interventions for each client who has depression." ANSWER: RATIONALE: While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors are consistent with this condition?: 1. the client needs excessive external input to make everyday decisions ANSWER: RATIONALE: A nurse is caring for a child who is taking Methylphenidate. The nurse should monitor the child for which adverse effect?: 1. weight gain ANSWER: RATIONALE: A nurse is caring for a client with antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?: 1. controls anger outbursts to avoid being places in seclusion ANSWER: RATIONALE: A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?: 1. panic ANSWER: RATIONALE: A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?: 1.
confront the staff member ANSWER: RATIONALE: A nurse is caring for a patient who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the patient is using a positive coping mechanism?: 1. "I will limit my drinking to the weekends." ANSWER: RATIONALE: A nurse is creating a plan of care for a patient who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions is to be included in the plan?: 1. document the client's behavior every 8 hr renew the prescription for the client every 4 hr A nurse is planning care for a patient who has depression and has made frequent suicide attempts. Which statement indicates the patient has a decreased risk for suicide?: 1. "I'm relieved now that my financial affairs are in order." ANSWER: RATIONALE: A nurse is reviewing routine labs for several patients who are taking lithium carbonate. Which of the following clients should be further assessed for findings indicating lithium toxicity?: 1. a client who has a fasting blood glucose of 80 mg/dL ANSWER: RATIONALE: A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?: 1. amenorrhea ANSWER: RATIONALE: A nurse is planning care for a preschool-age child who has ADHD. Which interventions should be identified as the priority?: 1. decrease distractions during meal times ANSWER: RATIONALE: A nurse is reviewing the chart of a patient who has dissociative amnesia. Which findings should the nurse expect?: 1. the client was seriously injured while under the influence of alcohol ANSWER: RATIONALE: A nurse is caring for a client who has a recent diagnosis of Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?: 1. inability to recognize family members frequently misplaces objects Caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority?: 1. encourage expression of feelings ANSWER: RATIONALE: A nurse is assessing for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?: 1. the client is married ANSWER: RATIONALE: A nurse is admitting a patient who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?: 1. encourage the client to drink 125 mL of fluid each hour while awake ANSWER: RATIONALE: A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The patient with depression reports, "That man in my room never sleeps and he keeps me up, too." Which of the following is an appropriate action by the nurse?: 1. move the client who has bipolar disorder to a private room ANSWER: RATIONALE: A nurse is planning care for a patient who is to undergo electroconvulsive therapy (ECT). Which actions should be included in the plan of care?: 1. administer Phenyoin 30 min prior to the procedure ANSWER: RATIONALE: A nurse is obtaining a mental health history for an older adult patient. Which of the following actions should the nurse plan to take?: 1. raise the pitch of the voice when speaking to the client
ANSWER: RATIONALE: A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?: 1. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." ANSWER: RATIONALE: A nurse is planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention?: 1. provide teaching about the use of positive coping
mechanisms ANSWER: RATIONALE: A nurse in a mental health clinic is caring for a patient who has bipolar disorder and reports that she stopped taking Lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the patient to stop taking the medication?: 1. sore throat ANSWER: RATIONALE: A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?: 1. arrange one-to-one observation of the client ANSWER: RATIONALE: A nurse is a mental health facility is caring for a patient with schizophrenia. Which of the following places puts the patient at the greatest risk for self-directed injury or injuring others?: 1. inability to communicate with others ANSWER: RATIONALE: A nurse is facilitating a community meeting for acute care of clients. One patient is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?: 1. tell the client that he must talk less or he will be removed from the meeting ANSWER: RATIONALE: A home health nurse is assessing an older adult patient whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?: 1. increased confusion ANSWER: RATIONALE: A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?: 1.
emotional lability ANSWER: RATIONALE: A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the suspicion of delirium?: 1. slow onset ANSWER: RATIONALE: A nurse is caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer Benztropine 2 mg IM?: 1. shuffling gait ANSWER: RATIONALE: A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery?: 1. "I consciously decrease my breathing rate when I feel anxious." ANSWER: RATIONALE: A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue?: 1. an adolescent family member who questions parental authority ANSWER: RATIONALE: A nurse is caring for a client who is experiencing a panic attack. Which action should the nurse take?: 1. orient the client to person, place, and time ANSWER: RATIONALE: A nurse is planning care for a patient who has bipolar disorder and is experiencing mania. Which intervention should the nurse include in the plan of care?: 1. encourage the client to participate in group therapy ANSWER: RATIONALE: A nurse observes a patient pushing on the locked unit door. Which statement should the nurse make?: 1. "It appears as though you would like to open the door." ANSWER: RATIONALE: A charge nurse observes an assistive personnel (AP) slapping an older adult client. After moving the client to safety, which is the priority action?: 1. complete an incident report ANSWER: RATIONALE: A student says "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience as: 1. culturally influenced mild anxiety A client with an abdominal mass is scheduled for a biopsy. The client has difficulty understanding and asks, "What do you mean? Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety?: 1. mild moderate For a client experiencing panic, which nursing intervention should be implemented first?: 1. teach relaxation techniques provide calm, brief, directive communication A client experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: 1. "What would you like me to do to help you?" "I'm not sure I understand. Give me an example." A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?: 1. "I check where my car keys are eight times." "I check where my car keys are eight times." A soldier served in combat zones in Iraq. When is it most important for the nurse to screen for signs and symptoms of PTSD?: 1. immediately upon return to US screening should be ongoing Which assessment finding best supports dissociative fugue? The client states: 1. "I cannot recall why I'm living in this town." "I cannot recall why I'm living in this town." The nurse who is counseling a client with dissociative identity disorder should understand that the assessment of highest priority is: 1.
risk for self-harm risk for self-harm Two nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The manager had a headache the day I was interviewed." Which defense mechanism is evident?: 1. introjection splitting What type of patient would you see in a hospital setting - mania or hypomania? mania What types of food do you give someone with mania? finger foods A client with bipolar is dancing nonstop and says "Do you like my moves? I got the grooves, and I'm not a bit tired" how should the nurse document client's mood?: 1. euphoric euphoric A person was online for over 24 hours, posting tweets and asking politicians to join Twitter. What features of mania are evident?: 1. increased muscle tension poor judgment A client with bipolar becomes hyperactive and threatens to hit another client. What is the nurse's best response?: 1. "Stop that - no one did anything to provoke you" "Do not hit anyone - we can help you." Your client has been started on Lithium. What are some side effects that you should be most concerned with?: 1. nausea blurred vision Your client with bipolar had a medication added to his regimen. Which of the following atypicals would you expect to see?: 1. Zoloft Latuda Your client with a history of depression, hopelessness and helplessness is admitted to inpatient psych. What is your priority intervention?: 1. orient client to unit and daily schedule request client to sign no self-harm contract A client with depression says, "No one cares about me. I'm worthless." Today the client is wearing a new shirt. Which remark by the nurse supports building a positive self-esteem?: 1. "You look nice today." ANSWER: RATIONALE: A nurse working with a client with depression may be at risk for: 1. guilt and despair ANSWER: RATIONALE:
Priority interventions for a client with depression should include: 1. distracting the client from self-absorption careful unobtrusive observation at all times Which tool would you likely use for an elderly client to assess for depression?: 1. zung ANSWER: RATIONALE: Your client has been started on an SSRI. Which medication is he most likely on?: 1. Haldol ANSWER: RATIONALE: Your client on Parnate (Tranylcypromine) needs to avoid special foods and meds. Which diet would be best for him?: 1. mac and cheese, hot dogs, banana mashed potatoes, ground beef Your client is scheduled for ECT in the morning. What is a priority intervention?: 1. have family watch ECT video ensure medical workup has been completed Your client is scheduled for Transcranial Magnetic Stimulation (TMS). He asks you if this is a valid treatment. What is your most therapeutic response?: 1. "Don't ask me, ask your doctor." "There is some evidence that TMS is helpful for depression." Recommended textbook solutions Myers' Psychology for the AP Course3rd EditionC. Nathan DeWall, David G Myers 955 solutions A Concise Introduction to Logic13th EditionLori Watson, Patrick J. Hurley 1,967 solutions Myers' Psychology for AP2nd EditionDavid G Myers 900 solutions A Concise Introduction to Logic12th EditionPatrick J. Hurley 1,933 solutions Sets with similar termsMental Health Practice 2016 A60 terms Lynda_Cesar ATI - Mental health60 terms colbie_crenshaw Sets found in the same folderPsych Exam 1240 terms lovedance2 EX 1 PT 297 terms bhagma Psych 525 terms michellekorte Psych 326 terms michellekorte Other sets by this creatorAd. Health Exam 350 terms lovedance2 Ad. Health Exam 2255 terms lovedance2 OB Exam 298 terms lovedance2 Ad. Health Exam 1423 terms lovedance2 Verified questionsQUESTION Which of the following best describes the relationship between gender and orgasm? a. You can use fMRIs to identify when orgasm occurs in men, but this method is unreliable in women. b. Men describe orgasm in physical terms and women describe orgasm in emotional terms. c. Orgasm activates subcortical regions in men and cortical regions in women. d. Men and women describe orgasm similarly. e. Orgasm serves evolutionary purposes in women but not in men. Verified answer PSYCHOLOGY A humanistic psychologist working with some poets might ask which of the following questions? a. How can we get them to reach their highest potential? b. How did their childhood experiences impact their current behavior? c. How have rewards and punishments shaped their behavior? d. How do society’s attitudes affect their writing topics? e. How do their brains differ from those of other successful people? Verified answer
PSYCHOLOGY Students with higher scores on anxiety scales were found to have lower scores on standardized tests. What research method would show this relationship? Why can no cause-effect conclusion be drawn from the results? Verified answer QUESTION Describe one key factor present in passionate love and two key factors present in companionate love. Verified answer Other Quizlet setsPulmonary Diseases Quiz21 terms quizlette27995488 Advanced Java Chapter 14 Quiz10 terms Wreck_Records Marketing Test 241 terms paytan_rhea Ethics 542318 terms lhcounce Related questionsQUESTION What concept has largely replaced "short-term" memory? 7 answers QUESTION what do people with psychiatric disorders commonly do 15 answers QUESTION (T/F): 1-800-273-TALK is a suicide prevention hotline. 2 answers QUESTION Which student statement regarding the recovery model indicates that further teaching is needed? 2 answers What is the first line intervention for bipolar disorder?Lithium. Lithium is the first-line choice for preventing mood instability and treating mania. This agent is successful in treating aggressive behavior during acute manic episodes, and it is also the most successful long-term treatment for bipolar disorder.
What are treatment goals for bipolar disorder?Treatment of bipolar disorder generally begins with the goal of bringing a patient with mania or depression to symptomatic recovery and stable mood. Once stable, the goal progresses to reduction of subthreshold symptoms and relapse prevention.
What is the single most successful treatment approach for bipolar disorder?Lithium, introduced by John Cade in 1949, remains the best established long-term treatment for bipolar disorder.
What is the most common and most effective treatment for bipolar disorders?Lithium. In the UK, lithium is the main medicine used to treat bipolar disorder. Lithium is a long-term treatment for episodes of mania and depression. It's usually prescribed for at least 6 months.
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Which interventions would be included in the plan of care for a client with bipolar disorder?
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