MH – Practice 2 of 3 – Flashcards
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An adult client assaults another client and is placed in restraints at 1345 hours. Which statement should a nurse further assess while the client is in restraints? A) "I hate all of you!" B) "My fingers are tingly." C) "You wait 'till I tell my lawyer." D) "It was John who started it. He should be in here."
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B) "My fingers are tingly."
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After assaulting another client, an adult client is placed in restraints. After the client is removed from restraints, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. This discussion is considered to be: A) Post-restraint intervention. B) Treatment planning. C) Post-conference. D) Debriefing.
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D) Debriefing.
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How often should a nurse plan to observe a client in restraints? A) At least every 5 minutes B) Continually C) At least every 15 minutes D) Every 2 hours
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C) At least every 15 minutes
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Physical restraint is considered a beneficial intervention for select clients and is based on which premise? A) Clients with poor boundaries do not respond to verbal redirection and they need firm and consistent limit setting. B) Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C) Clients with antisocial tendencies need to submit to authority. D) Whereas clients with behavioral dysfunction need behavioral intervention, clients with cognitive dysfunction require cognitive intervention.
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B) Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others.
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A client with paranoid schizophrenia is admitted after attempting to injure his father with a butcher knife. A nurse who writes the client's care plan gives him the priority nursing diagnosis of risk for other-directed violence. Based on this nursing diagnosis, which should be the priority goal for this client during hospitalization? A) The client will not verbalize anger or hit anyone. B) The client will verbalize anger rather than hit others. C) The client will not harm himself or others. D) The client will be restrained if he becomes verbally or physically abusive.
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C) The client will not harm himself or others.
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Certain client psychiatric diagnoses have been associated with risk factors for assaultive behaviors. Which diagnoses have been associated with violent behavior? Select all that apply. A) Schizophrenia B) Bipolar disorder C) Somatization disorder D) Dependent personality disorder E) Borderline personality disorder F) Substance use disorder
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A) Schizophrenia B) Bipolar disorder E) Borderline personality disorder F) Substance use disorder
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Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A) Prior treatment for schizophrenia B) History of violence C) Family history of violence D) Recent discharge from a drug rehabilitation program
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B) History of violence
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Because of the high incidence of violence among psychiatric clients, nurses in psychiatric units commonly have violence-intervention protocols. Which intervention would be contraindicated as part of such a protocol? A) Administration of psychotropic medication B) Soothing the client by stroking an arm or shoulder C) Application of leather restraints D) Observation for symptoms of the prodromal syndrome
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B) Soothing the client by stroking an arm or shoulder
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A client with a history of violence begins to lose control of his anger, and a nurse decides that an intervention is warranted. The client cannot be "talked down," and he refuses medication. Which is the most appropriate nursing intervention? A) Call for assistance from the assault team. B) Ask the ward clerk to put in a call for the physician. C) Make the client go to his room. D) Tell the client that if he does not calm down, he will be placed in restraints.
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A) Call for assistance from the assault team.
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A 16-year-old client assaults another client in a psychiatric unit and is unable to be managed through less restrictive means. The client is placed in restraints at 1345 hours. When should a nurse remind the physician to see this client? A) 1445 h B) 1545 h C) 1745 h D) 1945 h
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B) 1545 h
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A nurse is preparing a client for electroconvulsive therapy (ECT). Which state is induced during ECT? A) Unconsciousness B) Grand mal seizure C) Catatonia D) Petit mal seizure
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B) Grand mal seizure
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A client is admitted to a psychiatric unit following a suicide attempt and is scheduled for electroconvulsive therapy (ECT). Which documentation accurately describes the suicide assessment of a client undergoing ECT? A) Suicide assessment continues to remain vigilant during the course of ECT. B) Suicide assessment is on hold until the course of ECT is completed. C) Suicide assessment is unnecessary while the client undergoes ECT because he or she won't remember being depressed. D) Suicide assessment remains the highest priority. The client should remain on one-to-one observation throughout the course of ECT.
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A) Suicide assessment continues to remain vigilant during the course of ECT.
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A client gives consent to begin electroconvulsive therapy (ECT) for the treatment of severe depression. After receiving two of nine treatments, the client approaches the nurses' station and says, "I don't want anymore ECT. I can't remember what I had for lunch. Tell the doctor I don't want it!" Which is the most appropriate nursing response? A) "After you begin the course of treatments, you must complete all of them." B) "You'll need to talk with your doctor about what you're thinking." C) "It is within your right to discontinue the treatments at this time, but let's talk about your concerns a little more." D) "Memory loss is a rare side effect of the treatment. I don't think it is related."
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C) "It is within your right to discontinue the treatments at this time, but let's talk about your concerns a little more."
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After undergoing two electroconvulsive therapy (ECT) treatments, a client decides to discontinue the therapy. The client then changes her mind and continues with ECT treatment. Later that week, the client refuses to get dressed, eat meals in the dining area, or go to group therapy. When planning care, which nursing diagnosis should be the lowest priority at this time? A) Anxiety related to confusion and memory loss B) Risk for injury related to post-ECT confusion and memory loss C) Disturbed thought process related to confusion and memory loss D) Activity intolerance related to post-ECT confusion and memory loss
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D) Activity intolerance related to post-ECT confusion and memory loss
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After undergoing two electroconvulsive therapy (ECT) treatments, a client decides to discontinue the therapy. The client then changes her mind and continues with ECT treatment. Later that week, the client refuses to get dressed, eat meals in the dining area, or go to group therapy. Based on this information, which is the most appropriate nursing intervention? A) Allowing the client to remain on bed rest B) Encouraging the client to join the milieu at increasingly greater intervals C) Locking the client's door so that the client cannot remain in her room from 0700 to 1900 D) Discharging the client and allowing her to continue with treatments as an outpatient
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B) Encouraging the client to join the milieu at increasingly greater intervals
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A client who is undergoing electroconvulsive therapy (ECT) treatment awakens 2 hours before the ECT begins, and asks, "Can I please get something to eat? I missed dinner last night because I wasn't feeling well." Which is the most appropriate nursing response? A) "Go ahead and grab something light, such as crackers." B) "You'll need to ask the doctor. He'll be in shortly." C) "You may eat something, but avoid anything containing tyramine, such as aged meats and cheeses." D) "I realize you are very hungry, but you cannot eat before treatment because it can lead to complications."
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D) "I realize you are very hungry, but you cannot eat before treatment because it can lead to complications."
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A client undergoing electroconvulsive therapy (ECT) is given pure oxygen during and after the treatment because: A) Electrical stimulation temporarily causes blood pressure, pulse, and respiration to cease. B) Succinylcholine chloride (Anectine) paralyzes the respiratory muscles. C) Seizure occasionally blocks the airway, leading to complications. D) Electrical stimulation causes the trachea to constrict.
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B) Succinylcholine chloride (Anectine) paralyzes the respiratory muscles.
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During the recovery period immediately after electroconvulsive therapy (ECT), a nurse should place the client in which position? A) Lying on his or her side to prevent aspiration B) In high Fowler's position to promote consciousness C) In Trendelenburg's position to promote blood flow to the vital organs D) Prone to prevent self-harm
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A) Lying on his or her side to prevent aspiration
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The family of a client who is to receive electroconvulsive therapy (ECT) asks a nurse what to expect when they visit the client after a treatment. Which is the most appropriate nursing response? A) "There will be no noticeable change in his behavior" B) "There's no point in coming. He won't remember your visit." C) "He will be very confused so it would be best not to visit him." D) "There will probably be a temporary and expected loss of memory for recent events."
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D) "There will probably be a temporary and expected loss of memory for recent events."
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A nurse develops a plan of care for a client who is receiving a series of electroconvulsive therapy (ECT) treatments in a hospital. Which should be the priority nursing diagnosis for this client? A) Anxiety related to receiving ECT B) Knowledge deficit related to receiving ECT C) Confusion related to the side effects of ECT D) Risk for injury related to the risks and side effects of ECT
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D) Risk for injury related to the risks and side effects of ECT
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A nurse teaches a family what to expect immediately after their loved one receives electroconvulsive therapy (ECT) treatment. Which statement by a family member should indicate to the nurse that further teaching is needed? A) "He will most likely wake up right away and no longer be depressed." B) "He will probably be confused and somewhat disoriented." C) "He will be sleepy and very likely sleep for a number of hours." D) "He may experience some soreness in his muscles."
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A) "He will most likely wake up right away and no longer be depressed."
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A client who is learning about electroconvulsive therapy (ECT) treatment asks a nurse "Isn't this treatment dangerous?" Which is the most appropriate nursing response? A) "No, this treatment is absolutely safe." B) "There are some risks involved, but the benefits outweigh the risks." C) "There are some risks involved, but you will have a thorough examination in advance to ensure that you are a good candidate for the treatment." D) "There are some side effects to the treatment, but they are not life threatening."
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C) "There are some risks involved, but you will have a thorough examination in advance to ensure that you are a good candidate for the treatment."
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Psychiatric nurses often care for clients who are preparing for or have undergone electroconvulsive therapy (ECT). Which statement is accurate regarding ECT? A) Electrical stimulation to the brain produces a grand mal seizure. B) Maximal muscle movement is required to ensure efficacy of the treatment. C) The client will sleep for about 12 hours after treatment. D) The client will fully recall what occurred during the treatment.
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A) Electrical stimulation to the brain produces a grand mal seizure.
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A nurse tells a client that an injection of medication called atropine sulfate (Atropen) will be administered about 30 minutes before electroconvulsive therapy (ECT) treatment. Which rationale should the nurse provide to the client for giving this medication? A) "It will alleviate your anxiety." B) "It will relax your muscles." C) "It will decrease secretions." D) "It will put you to sleep for the treatment."
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C) "It will decrease secretions."
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A physician orders a medication to be administered by a nurse 30 minutes before each electroconvulsive therapy (ECT) treatment. This medication will decrease secretions and will maintain heart rate during the convulsion. Which medication would the physician most likely prescribe for this purpose? A) Thiopental sodium (Pentothal) B) Atropine sulfate (Atropen) C) Succinylcholine (Anectine) D) Clonazepam (Klonopin)
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B) Atropine sulfate (Atropen)
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A nurse notes that multiple clients are scheduled for electroconvulsive therapy (ECT) over the next month. For which conditions is ECT indicated? Select all that apply. A) Major depression B) Mania C) Schizoaffective disorder D) Obsessive-compulsive disorder E) Antisocial personality disorder
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A) Major depression B) Mania C) Schizoaffective disorder
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A client will be undergoing electroconvulsive therapy (ECT). Which assessments should be performed before the client is cleared for ECT treatment? Select all that apply. A) Cardiovascular exam B) Pulmonary exam C) Physical examination D) Blood samples E) Urine samples
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A) Cardiovascular exam B) Pulmonary exam C) Physical examination D) Blood samples E) Urine samples
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Complementary therapy is especially suitable to nursing because both practices approach the concept of health: A) Medically. B) Holistically. C) Diagnostically. D) Nontraditionally.
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B) Holistically.
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A nurse asks a client, "Are you taking any herbal medicines or other over-the-counter supplements?" The client asks, "Well, yeah, isn't everybody? Why do you need to know?" Which is the most appropriate nursing response? A) "Actually, I probably do not need to know. We can move on to the next question." B) "The government keeps a close eye on the quality of those products, but we want to make sure they won't interfere with any other medications." C) "Those products are exceptionally safe; these questions are just a formality." D) "Those remedies are not subjected to rigorous FDA standards, and they may interact with prescription medications and other medical treatments."
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D) "Those remedies are not subjected to rigorous FDA standards, and they may interact with prescription medications and other medical treatments."
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A young woman with severe nausea and diarrhea presents in an emergency department for treatment. She has taken St. John's wort at the recommended daily dosage several times that day. After she has been stabilized, she tells a nurse that she thought, "If two capsules are good, four must be better!" Which is the most appropriate nursing response? A) "Herbal medicines are more likely to cause adverse reactions." B) "You can overdose on herbal medicines just as you can with prescription medications, so more is not always better." C) "Because the FDA does not regulate herbal remedies, who knows what was in those capsules?" D) "Certain companies are better than others. Always frequent reputable stores."
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B) "You can overdose on herbal medicines just as you can with prescription medications, so more is not always better."
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A client with chronic lower back pain says, "My nurse practitioner told me to check out acupuncture. He said it might help me along with the medications and physical therapy he's ordering for me." What type of therapy is the nurse practitioner most likely recommending? A) Alternative therapy B) Complementary therapy C) Physiotherapy D) Biopsychosocial therapy
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B) Complementary therapy
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A client with chronic lower back pain asks, "How does acupuncture work?" Which is the most appropriate nursing response? A) "Western philosophy believes that acupuncture stimulates the body's release of pain-fighting chemicals called endorphins." B) "We have no idea why it works, or even if it really works." C) "Acupuncture works by encouraging the body to increase its development of serotonin and norepinephrine." D) "The nurse practitioner will need to answer that question for you."
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A) "Western philosophy believes that acupuncture stimulates the body's release of pain-fighting chemicals called endorphins."
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A nurse is assessing a client who states, "I was thinking of getting a weekly massage." Which condition is contraindicated for massage therapy? A) Anxiety B) Chronic back pain C) Insomnia D) Phlebitis
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D) Phlebitis
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A home health nurse is visiting an elderly client who is in good health but is lonely and depressed. Which therapy could be used to decrease loneliness and depression in nursing home residents? A) Yoga B) Pet therapy C) Massage D) Chiropractic therapy
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B) Pet therapy
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A client asks a nurse to explain the difference between complementary and alternative medicine. Which is the most appropriate nursing response? A) "Alternative medicine is more radical than complementary medicine." B) "Complementary therapies partner alternative approaches with traditional medical practice." C) "Complementary medicine disregards traditional medical approaches." D) "Alternative and complementary medicine mean the same thing."
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B) "Complementary therapies partner alternative approaches with traditional medical practice."
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A client begins antidepressant therapy and asks a nurse whether she can continue taking St. John's wort. Which is the most appropriate nursing response? A) "You shouldn't use these medications at the same time because they interact with one another." B) "Your doctor can tell you if you can use it while taking antidepressants." C) "Because it's an over-the-counter product, there shouldn't be any adverse reactions." D) "St. John's wort has not been shown to be effective in the treatment of depression, so taking it is unnecessary."
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A) "You shouldn't use these medications at the same time because they interact with one another."
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A client who prefers to use St. John's wort and psychotherapy in lieu of antidepressant therapy asks for tips on using herbal remedies. Which is the most appropriate nursing teaching? Select all that apply. A) Select a reputable brand. B) Increased dosages do not lead to improved effectiveness. C) Monitor carefully for reactions to new products. D) Avoid using other herbal remedies when taking St. John's wort.
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A) Select a reputable brand. B) Increased dosages do not lead to improved effectiveness. C) Monitor carefully for reactions to new products.
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A client who has been taking antidepressant therapy for 6 weeks complains of persistent fatigue and low energy; symptoms that were originally thought to be associated with depression. What nutritional deficiency should the nurse suspect? A) Vitamin A deficiency B) Vitamin C deficiency C) Iron deficiency D) Folic acid deficiency
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C) Iron deficiency
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A client inquires about the practice of therapeutic touch. Which statement regarding therapeutic touch is most accurate? A) "Therapeutic touch has been shown to improve mood and energy level." B) "Heat is felt by the therapist where energy is blocked and that site is massaged." C) "Therapeutic touch is the treatment of choice for lower back pain and spasms." D) "Heat is felt where energy flow is optimal. Surrounding sites are massaged."
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B) "Heat is felt by the therapist where energy is blocked and that site is massaged."
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Several nurses are discussing alternative health practices. One nurse says, "It's a bogus practice. There's no value in it. It's like a fad and it will fade away." Which is the most appropriate response by an informed nurse? A) "Complementary therapies are similar to nursing practice in that they take a holistic approach to healing." B) "The government is conducting research to prove that these therapies are ineffective." C) "Complementary therapies are not compatible with traditional nursing practice." D) "There's no evidence to show that any complementary therapy is effective."
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A) "Complementary therapies are similar to nursing practice in that they take a holistic approach to healing."
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An elderly client asks a nurse to recommend a homeopathic remedy that improves memory. Which herbal remedy is thought to improve memory and blood circulation? A) Ginkgo B) Ginseng C) Kava kava D) St. John's wort
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A) Ginkgo
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A client's parents who both died in their sixties developed cancers linked to a high-fat diet. When teaching the client about diet, a nurse would recommend moderation of which foods? A) Fruits and grains B) Meat and cheese C) Meat and starches D) Reduced fat milk and cereal
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B) Meat and cheese
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A client who is feeling mildly depressed after a break up with her boyfriend wishes to try an herbal supplement instead of medication. Which option might a therapist recommend? A) Chamomile B) Echinacea C) St. John's wort D) Feverfew
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C) St. John's wort
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A client who is seeing a chiropractor for low back pain learns that the chiropractor documented some displacement of vertebrae in the client's spine. Which term, provided by a nurse, describes what these displacements are called? A) Maladjustments B) Manipulations C) Meridians D) Subluxations
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D) Subluxations
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A long-term care nurse arranges for yoga classes for the residents of the facility. Which techniques will be used when the residents perform yoga? Select all that apply. A) Deep breathing B) Meditation C) Balanced body postures D) Aerobics
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A) Deep breathing B) Meditation C) Balanced body postures
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Several clients in an assisted living facility want to participate in massage therapy. A nurse knows that massage therapy is contraindicated in which conditions? Select all that apply. A) Macular rash B) Acute viral infection C) Old injury, now healed D) New injury, still somewhat painful E) Whiplash
answer
A) Macular rash B) Acute viral infection D) New injury, still somewhat painful
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A graduate nurse is assigned a client who is mentally handicapped. Which developmental characteristic should the new nurse recognize as typical of a person with severe mental retardation? A) The client can perform some self-care activities independently. B) The client has little, if any, speech development. C) The client's psychomotor skills are usually not affected, except for possible coordination problems. D) The client's wants and needs are often communicated by acting out behaviors.
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D) The client's wants and needs are often communicated by acting out behaviors.
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Which nursing interventions related to self-care would be most appropriate for a moderately mentally-retarded teenager? A) The nurse will perform all self-care to avoid injury to the client. B) The nurse will provide simple directions and praise the client's efforts to independently perform self-care. C) To promote autonomy, the nurse will not interfere with the client's self-care regimen. D) To promote bonding, the nurse will encourage family members to perform the client's self-care.
answer
B) The nurse will provide simple directions and praise the client's efforts to independently perform self-care.
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The mother of a child with a new diagnosis of an autistic disorder has come to an emergency department of a children's hospital after an episode of head banging by her son. She is sobbing as a nurse enters the room. Upon inquiring, the mother cries, "I'm such a terrible mother. What did I do to cause this behavior in my son?" Which is the most appropriate nursing response concerning the cause of autism? A) "Researchers really don't know what causes autism." B) "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure or function that are beyond your control are to blame." C) "The mother appears to play a greater role in the development of the disorder than the father." D) "Lack of early infant bonding with the mother may be a cause of autism. Did you breast-feed or bottle-feed?"
answer
B) "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure or function that are beyond your control are to blame."
