Saunders Mental health book test 2 questions and answers, Exams of Health psychology

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questions and answers

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? - correct answer "You seem restless; tell me what is happening." The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? - correct answer The death of a loved one The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? - correct answer "What leads you to seek help now?" The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse would consider which factor? - correct answer A client's response to a crisis is individualized, and what constitutes a crisis for one client may not constitute a crisis for another client.

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The nurse in the emergency department is caring for a young victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How would the nurse interpret these behaviors? - correct answer. Reactions to a devastating event A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? - correct answer "You sound very upset. Are you thinking of hurting yourself?" The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. - correct answer. Acknowledge the client's behavior.

. Assist the client to an area that is quiet. Maintain a safe distance from the client.

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Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? - correct answer The adolescent gives away a DVD and a cherished autographed picture of a performer. The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? - correct answer Assess and treat the wound sites. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention would the nurse include in the plan? - correct answer. Increasing the level of suicide precautions The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention would the nurse include in the plan of care? - correct answer One-to-one suicide precautions The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority

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information would be included in the discharge instructions? - correct answer Information regarding shelters A victim of a sexual assault is being seen in the crisis center. The client states, "I still feel as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? - correct answer "Tell me more about the incident that causes you to feel as if the rape just occurred." A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? - correct answer Assigning to the client a staff member who will remain with the client at all times.

. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. - correct answer I keep reliving the robbery." "I see that face everywhere I go."

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"I have to wash my hands over and over again many times." A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how would the nurse administer the dose? - correct answer At the same time each evening A client with schizophrenia has been started on medication therapy with clozapine. The nurse would assess the results of which laboratory study to monitor for adverse effects from this medication? - correct answer White blood cell count A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? - correct answer Avoid drinking alcohol while taking this medication. The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information would the nurse incorporate in the discussion? - correct answer Increase fluids and bulk in the diet.

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The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction would the nurse provide to the client? - correct answer Get up slowly when changing positions. The nurse is teaching a client who is being started on imipramine about the medication. The nurse would inform the client to expect maximum desired effects at which time period following initiation of the medication? - correct answer In 2 to 3 weeks A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse would instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. - correct answer Crackers, Tossed salad The nurse notes that a client with schizophrenia who is receiving an antipsychotic medication is moving the mouth, protruding the tongue, and grimacing while watching television. The nurse determines that the client is experiencing which medication complication? - correct answer Tardive dyskinesia

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The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding specific side and adverse effects of the medication? - correct answer Gastrointestinal dysfunctions A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? - correct answer Rapid heartbeat or anxiety A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? - correct answer Toxic A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? - correct answer Frequent handwashing with hot, soapy water

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A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? - correct answer Seizure activity A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? - correct answer Client arrives at the clinic neat and appropriate in appearance. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care? - correct answer Ask the client about the amount of drug use and its effect Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. - correct answer 1. Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically.

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Address hallucinations therapeutically. The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement - correct answer "I no longer feel that I deserve the beatings my partner inflicts on me." A hospitalized client with a history of alcohol use disorder tells the nurse: "I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action would the nurse take? - correct answer Call the nursing supervisor. The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? - correct answer. Hypertension, changes in level of consciousness, hallucinations

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The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse? - correct answer "What do you find difficult about this situation?" A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? - correct answer Do you feel afraid that people are trying to hurt you A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially - correct answer. Use an indirect light source and turn off the television. A client is admitted to the mental health unit with a diagnosis of depression. The nurse would develop a plan of care for the client that includes which intervention? - correct answer A structured program of activities in which the client can participate When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?

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correct answer Identifying anxiety-producing situations A client is unwilling to go to church because the ex- spouse goes there and the client feels that the ex-spouse will laugh at the client. Because of this hypersensitivity to a reaction from the spouse, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? - correct answer Avoidant he nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention would the nurse initially implement? - correct answer Setting limits on the client's behavior A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit- and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? - correct answer Conversion disorder A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that

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this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention would the nurse implement?

correct answer Escort the client to their room, with the assistance of other staff. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? - correct answer Provide safety for the client and other clients on the unit. The nurse is preparing a client with schizophrenia and a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? - correct answer When I have command hallucinations, I'll call a friend for help." he nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the

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most appropriate nursing intervention? - correct answer Sit beside the client in silence with simple open-ended questions. The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention would the nurse include? - correct answer Avoid using a whisper voice in front of the client The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? - correct answer Writing A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which therapeutic response would the nurse make?

correct answer "It sounds as if you've been feeling like a failure for a while." The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which therapeutic response would the nurse make? -

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correct answer "Tell me more about your sleep over the past few nights." A client experiencing disturbed thought processes believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat? - correct answer. Using open-ended questions and silence client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? - correct answer it sounds as if you are feeling angry that your family continues to hope for you to be cured." On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care, anticipating which client behavior? - correct answer A willingness to participate in the planning of the care and treatment plan A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially? -

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correct answer Contact the client's primary health care provider. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse would provide which intervention for this client? - correct answer Monitor closely for harm to self or others. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would plan to tell the client that which is the first step in this 12-step program?

correct answer. Admitting to having a problem The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? - correct answer "I cannot discuss any client situation with you." The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the

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possible legal ramifications for the nurse associated with these interventions? Select all that apply. - correct answer Battery Assault False imprisonment The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. - correct answer Restating Active listening Maintaining a neutral response Providing knowledge and feedback What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? - correct answer Thank the client for the input, but inform the client that others now need a chance to contribute. A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? - correct answer Milieu therapy

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The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action would the nurse plan to engage in during the working phase of the nurse- client relationship? - correct answer Inquiring about and examining the client's feelings for any that may block adaptive coping