RN Mental health 2016 practice A – Flashcards
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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
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Report the occurrence to the charge nurse
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A nurse is caring for a client who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the client 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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A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care Encourage the client to participate in group therapy. Instruct the client to avoid napping during the day. Offer the client high-calorie finger foods frequently. Decrease the client's daily fiber intake.
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Offer the client high-calorie finger foods frequently
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A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, she does not respond. Which of the following actions should the nurse take before repeating the request to the client
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Allow the client time to collect her thoughts
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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 should the nurse include in the teaching
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Wear sunglasses when outdoors
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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
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Arrange one-to-one observation of the client
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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
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Establish screening programs to identify at-risk clients
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A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan
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renew the prescription for the client every 4 hr.
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A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine
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St. John's wort
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A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect
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Inappropriate dress
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A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan
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Monitor the client's cardiac rhythm during the procedure
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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 is consistent with this condition
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The client needs excessive external input to make everyday decisions
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During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take
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Assess the client for evidence of a perceptual disturbance
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A nurse is facilitating a community meeting for acute care clients. One client 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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A nurse is 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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A nurse in an emergency 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 the mother acknowledges her daughter's diagnosis
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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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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 nurse's suspicion of delirium
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Easily distracted
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A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "That man in my room never sleeps and he keeps me up, too." Which of the following is an appropriate action for the nurse to take
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Move the client who has bipolar disorder to a private room
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A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue
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Older children who are responsible for their younger sibling
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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
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mild
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A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include 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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A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the following statements indicates that client teaching regarding the medication has been effective
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"I should eat a regular diet with normal amounts of salt and fluids
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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
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Spending adequate time with a client who is verbally abusive
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A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client 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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A nurse is assessing a client 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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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
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Frequently misplaces object
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A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following places the client at the greatest risk for self-directed injury or injuring others
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Command hallucination
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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 initiate? (Select all that apply
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occupational, meal, physical, home
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A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority
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Remove unnecessary equipment from the child's surrounding
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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
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Instruct the client to avoid driving during initial therapy
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A charge nurse enters a client's room and observes an assistive personnel (AP) slapping an older adult client. After moving the client to safety, which of the following actions is the charge nurse's priority Complete an incident report. Determine if the client has been physically harmed. Provide emotional support to the client. Discipline the AP.
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Determine if the client has been physically harmed
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A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect
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Emotional lability
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A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero
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14
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A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following findings should the nurse expect
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The client was seriously injured while under the influence of alcohol
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A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse 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 nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make
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"I'll stay with you just in case you want to talk
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A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take
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Assist the client with deep-breathing exercises
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A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer's disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching
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Take this medication in the evening at bedtime
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A nurse is admitting a client 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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A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal
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Blood pressure 154/96 mm hg
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A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse 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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A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction
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Phenylephrine
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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
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Anhedonia
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A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings
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Tooth erosion
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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
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Shuffling gait (Parkinsonism)
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A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make "It appears as though you would like to open the door." "You will feel more comfortable after you've been here for a while." "It is okay to not want to be here." "You really shouldn't be pushing on the door."
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"It appears as though you would like to open the door
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A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization
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Temperature 35.6° C (96.1° F
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A nurse in a mental health clinic is caring for a client 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 client to stop taking the medication
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Hand tremor
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A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate
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Tachycardia
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A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide
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"It is easier to talk about my feelings now
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A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy
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Refrains from manipulating others to earn dining-room privileges
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A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data
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Diazepam 5 mg IV bolus
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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
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Call for a team of staff members to help with the situation
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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 receiving clozapine
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WBC 2500/mm3
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A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity
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A client who has a sodium level of 128 mEq/l
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A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect
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Greater risk of attempting suicide as affect and energy improve
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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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A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the client's ability to cope with this situation
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"To whom do you talk when you feel overwhelmed
