mental health practice 2016 A – Flashcards
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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 pt's ability to cope with this situation?
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"To whom do you talk when when you feel overwhelmed?"
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Caring for a pt who gave birth to a stillborn baby. Appropriate statement?
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"I'll stay with you just in case you want to talk."
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Assessing a pt who sustained injuries 12 hrs ago following a MVC. The blood alcohol lvl was 325 mg/dL. Findings that indicate alcohol withdrawal?
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BP 154/96 mm Hg
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New diagnosis of Azheimer's disease and is to start taking donepezil. Statement to be included in the teaching?
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"Take this medication in the evening at bedtime."
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Discussing a 12-step program with a pt who has alcohol use disorder and is in a n acute care facility undergoing detoxification. Information to be included in the teaching?
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The client should obtain a sponsor before discharge for an increased chance of recovery.
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Schizophrenic pt. is trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Appropriate action?
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Assess the client for evidence of a perceptual disturbance.
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Pt with major depression disorder and a NEW prescription for tranylcypromine. Which OTC med that the pt reports taking should alert the nurse to a potential adverse rxn?
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Phenylephrine
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Assessing a pt. with schizophrenia. Findings that are negative symptoms?
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Anhedonia
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ED nurse caring for a female adolescent who has a dx of bulimia nervosa and had a fainting episode. Statements by mother that acknowledges the daughter's dx?
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"She won't let me take the trash from her room. I'm concerned about what she has in there."
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Assessing a pt. who has major depressive disorder and has been receiving amitriptyline for 1 wk. Following expected outcome?
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Greater risk of attempting suicide as affect and energy improve.
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expected clinical manifestations of PTSD?
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Experiences feelings of isolation
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Criteria required for hospitalization of anorexia nervosa?
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Temperature 35.6*C (96.1*F)
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Pt is experiencing alcohol withdrawals. Which medication should be administered first?
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Diazepam 5 mg IV bolus
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Pt. with dx of depression and attending a group therapy. Nurse asks each member to identify 1 goal for the day. The pt. does not respond when it is her turn. Appropriate action before repeating the request to the pt.?
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Allow the client time to collect her thoughts.
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Nurse observes a pt who has acute mania hit another pt. First action to take?
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Call for a team of staff members to help with the situation.
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Teaching to a pt. who is to begin undergoing light therapy at home to treat seasonal affective disorder. Teaching to include?
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Wear sunglasses when outdoors.
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Pt. with bipolar disorder is to be discharged home with a prescription for lithium. Which statement indicates effective teaching?
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"I should eat a regular diet with normal amounts of salt and fluids."
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Action that is an example of the ethical principle of justice?
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Spending adequate time with a client who is verbally abusive.
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Nurse is working with a group of parents who recently lost a child. Appropriate action to take?
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Suggest forming a weekly support group for parents who have experienced the loss of a child.
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Planning care for a pt who has a new prescription for olanzapine. Priority intervention?
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Instruct the client to avoid driving during initial therapy.
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Preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Referrals to initiate? (select all)
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Occupational therapy Meal delivery services Physical therapy Home health services.
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Reviewing labs for a pt. who has schizophrenia and is taking clozapine. Which values are contraindications for receiving clozapine?
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WBC 2500/mm3
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Collecting a health hx from a pt. who is taking paroxetine for depression. The pt. is also taking herbal supplements. Which supplement has an adverse interaction with paroxetine?
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St. John's wort
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nursing care plan for pts who have depressive disorders. Statements that indicates an understanding of the teaching?
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"I will update the plan of care as a client's manifestations of depression change".
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A pt. is behaving in a way suggestive of dependent personality disorder. Behaviors that are consistent with this condition?
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The client needs excessive external input to make everyday decisions.
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Child taking methylphenidate should be monitored for which adverse effect?
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Tachycardia
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Pt. with antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Behavior that indicates effectiveness of the therapy?
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Refrains from manipulating others to earn dining-room privileges.
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Pt. with generalized anxiety disorder. At which level of anxiety should the nurse plan to teach the client relaxation techniques?
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Mild
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Nurse overhears another staff member make derogatory comments to the client. Appropriate action?
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Report the occurrence to the charge nurse.
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Caring for a pt. who has attempted suicide and has alcohol use disorder. Statement that indicates that the pt. is using a positive coping mechanism?
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"I will attend daily group therapy sessions to practice relaxation techniques."
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Creating a plan of care for a pt. who has been placed in seclusion after threatening to harm others on the unit. Interventions to be included in the plan?
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Renew the prescription for the client every 4 hrs.
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Planning care for a pt. who has depression and has made frequent suicide attempts. which statements indicates the pt. has a decreased risk for suicide.
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"It is easier to talk about my feelings now.
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Routine labs for several pts. who are taking lithium carbonate. Pt. that should be further assessed for findings indicating lithium toxicity?
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A client who has a sodium level of 28 mEq/L
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Expected findings for bulimia nervosa.
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tooth erosion.
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Planning care for a preschool-age child who has ADHD. Which interventions should be identified as the priority?
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Remove unnecessary equipment from the child's surroundings.
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Reviewing the chart of a pt. who has dissociative amnesia. Which findings should the nurse expect?
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The client was seriously injured while under the influence of alcohol
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Recent diagnosis of Alzheimer's disease. The pt's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?
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Frequently misplaces objects
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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?
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Use a therapeutic holding technique
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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?
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The client has COPD
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Admitting a pt. 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?
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Encourage the client to drink 125 mL of fluid each hour while awake.
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PT. with bipolar disorder is placed in a room with a client who has severe depression. The pt. with depression reports, "That man in my room never sleeps and he keeps me up, too." Appropriate action by the nurse.
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Move the client who bipolar disorder to a private room.
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Planning care for a pt. who is to undergo electroconvulsive therapy (ECT). Which actions should be included in the plan of care?
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Monitor the client's cardiac rhythm during the procedure.
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Obtaining a mental health hx for an older adult pt. Which of the following actions should the nurse plan to take?
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Interview the client in a private setting.
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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?
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"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."
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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?
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Establish screening programs to identify at-risk clients.
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Caring for a pt. who has bipolar disorder and reports that she stopped taking lithium 2 wks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the pt. to stop taking the medication?
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Hand tremors
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A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lbs. Avavilable is chlorpromazine syrup 10mg/5mL. How many mL should the nurse administer? (Round to nearest whole #)
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14 mL
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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.
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Arrange one-to-one observation of the client.
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Caring for a pt. with schizophrenia. Which places the pt. at the greatest risk for self-directed injurty or injuring others?
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Command hallucinations.
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Facilitating a community meeting for acute care of clients. 1 pt. is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?
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Ask group members to discuss their feelings about this client's monopolizing behavior.
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home health nurse is assessing an older adult pt. whose sibling is the primary caregiver. Which findings indicates neglect?
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Inappropriate dress
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Assessing a pt who has borderline personality disorder. Which of the following findings should the nurse expect?
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Emotional lability
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Performing cognitive assessment to distinguish delirium from dementia in a pt. whose family reports episodes of confusion. Which of the following assessment findings supports the suspicion of delirium.
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easily distracted.
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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?
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Shuffling gait
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Pt. has anxiety disorder. Which statement by the pt. indicates successful use of guided imagery?
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"I imagine myself lying on a quiet beach when I start to feel anxious"
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Assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue?
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Older children who are responsible for their younger siblings.
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Pt. who is experiencing a panic attack. Which action should the nurse take?
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Assist the client with deep-breathing exercises.
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Planning care for a pt. who has bipolar disorder and experiencing mania. Which intervention should the nurse include in the plan of care?
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Offer the client high-calorie finger foods frequently
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Observes a pt. pushing on the locked unit door. Which statement should the nurse make?
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"It appears as though you would like to open the door."
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Charge nurse observes an AP slapping an older adult pt. After moving the pt to safety, which is the priority action?
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Determine if the client has been physically harmed.