Foundations
A nurse decides to put a client who has psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurses’ actions are an example of which tort?
B. False imprisonment
Confining of a client to a specific area if the reason is inconvenience to staff.
A nurse is caring for a client who has Alzheimer’s disease and a new prescription for Donepezil. Which of the following actions should the nurse take?
A.) Monitor the client’s liver function while taking this medication
B.) Increase the dosage of this medication every 72 hr
C.) Offer the client a PRN NSAID while taking this medication
D.) Administer the medication at bedtime
D.) Administer the medication at bedtime
Donepezil is used to treat the manifestations of mild to moderate Alzheimer’s disease. The nurse should administer this medication at bedtime to reduce the risk of injury due to bradycardia and syncope.
A nurse is assessing a client who was diagnosed with schizophrenia. Which of the following client findings is considered a positive symptom of schizophrenia?
A. Hallucinations
B. Social withdrawl
C. Anergia
D. Flat affect
A. Hallucinations
Positive symptoms are grouped into the following categories: content of thought, form of thought, perceptions, and sense of self. The nurse should identify that hallucinations fall under the category of perception and cause the client to experience sensory perceptions that are not associated with reality. Other positive symptoms include delusions, depersonalization, and concrete thinking.
A nurse is reviewing the med records of multiple clients at a community mental health facility. Which of the following events is an example of a client experiencing a maturational crisis?
B. Marriage
Maturational crisis: naturally occurring event during a life span
A nurse is communicating with a client at an inpatient mental health facility. Which of the following actions by the nurse demonstrates the proper use of active listening
A. Offering self
B. Using silence
C. Paying attention to body language
D. Reflecting feelings
C. Paying attention to body language
Active listening involves identifying verbal and nonverbal communication by the client.
A nurse is caring for an older adult client who has a new prescription for amitriptyline to treat depression. Which of the following diagnostic tests should the nurse plan to perform prior to starting the client on this medication.
A.) Hearing examination
B.) Glucose tolerance test
C.) Electrocardiogram
D.) Pulmonary function tests
C.) Electrocardiogram
Amitriptyline can cause tachycardia and ECG changes. An older adult client is at risk for cardiovascular effects while using amitriptyline; therefore, an ECG should be performed prior to the start of therapy to obtain a baseline of the client’s cardiovascular status.
A nurse is interviewing a client who has anorexia nervosa. Which of the following findings should the nurse expect?
A. Poor personal hygiene habits
B. Strenuous exercise regimen
C. Grandiose behaviors
D. Intense fear of death
B. Strenuous exercise regimen
The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight.
A nurse is caring for a client who states, “I plan to commit suicide”. Which of the following assessments should the nurse identify as the priority?
B. Lethality of the method and availability of means
Priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.
A nurse is caring for a client who has anorexia nervosa. The client states, “If I gain weight, I’ll never get a boyfriend.” Which of the following cognitive distortions is the client displaying?
A.) Overgeneralization
B.) Personalization
C.) Emotional reasoning
D.) Catastrophizing
D.) Catastrophizing
Rationale:
A client displays the cognitive distortion of catastrophizing by assuming the worst possible outcomes will occur.
A nurse is assessing a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamine?
A.) The client exhibits paranoia
B.) The client reports having insomnia
C.) The client reports eating excessively
D.) The client has an increased heart rate
C.) The client reports eating excessively
When amphetamine is taken at a therapeutic dose, it causes appetite suppression. Abrupt withdrawal of amphetamine can result in abstinence syndrome in a client who is physically dependent on the medication. Indications of physical dependence include excessive eating, exhaustion, depression, prolonged sleep, and a craving for more amphetamine.
A nurse is providing teaching to the guardian of a female adolescent client who has bulimia nervosa. Which of the following statements by the guardian indicates an understanding of the teaching?
A. "My daughter is at risk for developing high blood pressure."
B. "It is important for my daughter to have regular dental checkups."
C. "I should weigh my daughter daily for several weeks."
D. "Bleeding during my daughter's period will increase."
B. "It is important for my daughter to have regular dental checkups."
For a client who has this disorder, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Therefore, frequent dental checkups are essential.
A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?
D. Ensure that the client swallows medication
Prevents hoarding of medication for an attempt to exceed the prescribed dose
A nurse is teaching a parent who has admitted to verbally abusing his children about stress management techniques. Which of the following strategies is the nurse providing?
A. Tertiary Prevention
B. Individual Psychotherapy
C. Family Psychotherapy
D. Primary Prevention
A. Tertiary Prevention
By offering stress management techniques to the abuser after the abuse has occurred. Tertiary prevention methods facilitate the rehabilitation process for both victims of violence and those who perpetuated it.
A nurse is assessing a client who is experiencing post-traumatic stress disorder (PTSD) following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe?
A.) Bupropion
B.) Phenelzine
C.) Mirtazapine
D.) Paroxetine
D.) Paroxetine
The nurse should expect the provider to prescribe paroxetine, an SSRI that is considered the first-line treatment for PTSD.
A nurse is assessing a newly admitted client who has generalized anxiety disorder and states, "I drink alcohol to forget the pain." The client is exhibiting a maladaptive response to which of the following defense mechanisms?
A. Compensation
B. Conversion
C. Projection
D. Suppression
A. Compensation
This is a defense mechanism by which a person covers a real or perceived problem or weakness. The client is temporarily attempting to block the constant worry of generalized anxiety disorder by drinking alcohol, which is a maladaptive method of increasing self-esteem.
A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?
B. Request that other staff remain close by
Staff will be able to intervene if necessary to ensure safety
A nurse is an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?
C. BPD and assaulted a homeless man with a metal rod
Client is a current danger to self or others
A nurse is assessing a client who has panic disorder and has been taking paroxetine. Which of the following assessments should the nurse identify as an adverse effect of the medication?
A.) Peripheral edema
B.) Chest congestion
C.) Shuffling gait
D.) Weight gain
D.) Weight gain
Weight gain is an expected adverse effect of paroxetine and other SSRIs. Other adverse effects include nausea, headaches, insomnia, and sexual dysfunction.
A nurse is assessing a client who has major depressive disorder. The client states, "I might as well be dead. I have always been a failure." Which of the following responses should the nurse make?
A. "Why do you think you feel this way?"
B. "You have a great deal to offer in life."
C. Let's discuss these feelings further."
D. "Feeling like a failure is expected with depression."
C. "Let's discuss these feelings further."
The nurse is using the therapeutic technique of exploring the client's feelings. The client comments indicate a risk for self-harm, and the nurse should further explore to confirm this.
A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action?
C. Move the client away from the patients
The behavior indicates that the client is at greatest risk for harming others.