Saunders PN Mental Health Review Questions & Answers with Verified Solutions, Exams of Nursing

Download Saunders PN Mental Health Review Questions & Answers with Verified Solutions and more Exams Nursing in PDF only on Docsity! Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need? - Correct Answe rSafety and Security The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. - Correct Answer-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice... An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action? - Correct Answer Notify the social worker to... Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply. - Correct Answer-My husband always brings... -I have bruises all over my... -My boyfriend yells and ... The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time? - Correct AnswerYou sound very unhappy. Are you thinking of harming yourself? The nurse in the emergency department is assisting in caring for a young female 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 The nurse notes that the client is withdrawn, confused, and at times physically Saunders PN Mental Health Review Questions & Answers with Verified Solutions instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? - Correct Answer"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone." A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment? - Correct AnswerMove the client to a quiet room and talk about his feelings. The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply. - Correct Answer-Avoidance -Hyperarousal -Reexperiencing Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client? - Correct Answer"It seems as if you or your daughter feel regret?" The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which? - Correct Answer"Our relationship is a therapeutic and a helping one." The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older Saunders PN Mental Health Review Questions & Answers with Verified Solutions client? Select all that apply. - Correct Answer-Suicide is a frequent cause of death among the older population. -Some indications of dementia may actually originate as depression. -Depression in an older person is likely to have physical manifestations. The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? - Correct AnswerThe client's report of self-destructive thoughts The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self- harm? - Correct Answerreported hopelessness Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client? - Correct Answer"Tell me about your difficulty sleeping." The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply. - Correct Answer-Stay with the client -Administer anxiolytics medications -Ensure the client is in an environment... The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates that which actions should the parents take? - Correct AnswerPlanning a non-food related activity Saunders PN Mental Health Review Questions & Answers with Verified Solutions An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply. - Correct Answer-Making -Providing -Ensuring The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings? - Correct AnswerUse open-ended questions and silence. Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse is caring for a client with severe depression. Which activity is appropriate for this client? - Correct AnswerDrawing The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority? - Correct AnswerRemoving the client from any immediate danger A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning? - Correct AnswerUntil the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition. The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination? - Correct AnswerThe client has the right to demand ... Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response? - Correct AnswerWhat do you mean by that? The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client? - Correct AnswerThe client asks to meet with a lawyer to take care of unfinished business. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. - Correct Answer-Communicate expected -Follow through -Assist the client -Be clear w/ the client Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? - Correct AnswerIncreasing the level of suicide precautions Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply. - Correct Answer-Poor limited setting -Staff inexperience -Provocative or controlling staff -Arbitrary revocation of privileges The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which Saunders PN Mental Health Review Questions & Answers with Verified Solutions would be the nurse's best response? - Correct Answer-Let me know if you change your mind... The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply. - Correct Answer-Hallucinations -Delusions -Neologisms A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care? - Correct AnswerAvoid joking or laughing in the presence of the client. Saunders PN Mental Health Review Questions & Answers with Verified Solutions -Asking The nurse is assigned to assist in the care of a client with obsessive- compulsive disorder (OCD). The nurse should place priority on which action when planning care for this client? - Correct AnswerEstablish a trusting nurse-client relationship. The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply. - Correct Answer-Provide -Decrease -Restrict The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the Saunders PN Mental Health Review Questions & Answers with Verified Solutions nurse implement? - Correct AnswerHelp the client with problem solving. A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate? - Correct Answer"What do you mean by that?" While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply. - Correct Answer-I'm going to do whatever... -I'll go and participate... Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply. - Correct Answer-Cutoffs -Conflict -Over involvement The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply. - Correct Answer-Zoophobia -Xenophobia -Agoraphobia -Glossophobia A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client? - Correct AnswerAccept the client as a person and make the client feel safe. Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? - Correct Answer"I cannot promise to keep a secret." An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? - Correct AnswerOffer to take the client to an examination room until he or she can be treated. The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply. - Correct Answer-Paralysis Saunders PN Mental Health Review Questions & Answers with Verified Solutions -Blindness -Paresthesia -Movement Disorder The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? - Correct Answer"Sometimes people hear things or voices others can't hear." A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? - Correct AnswerUse an indirect light source and turn off the television. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? - Correct AnswerA client receiving diagnostic tests Saunders PN Mental Health Review Questions & Answers with Verified Solutions Which client is most likely at risk to become a victim of elder abuse? - Correct AnswerA 90-year-old woman with advanced Alzheimer's disease A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority? - Correct AnswerLook for organic causes of the paralysis. Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply. - Correct Answer-Medication management -Monitoring and Documenting Behavioral -Notifying the health care provider... Saunders PN Mental Health Review Questions & Answers with Verified Solutions should respond with which question or statement? - Correct Answer"Are you fearful and think that others may want to hurt you?" An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? - Correct AnswerOffer to take the client to an examination room until he or she can be treated. A client 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 therapeutic response should the nurse make to the client? - Correct Answer"You're feeling angry that your family continues to hope for you to be 'cured'?" Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? - Correct AnswerThe client will participate in the treatment plan. The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? - Correct AnswerContact the primary health care provider (PHCP). A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the Saunders PN Mental Health Review Questions & Answers with Verified Solutions nurse expect to note? - Correct AnswerThe client presents a harm to self. Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? - Correct AnswerGet a written prescription from the primary health care provider (PHCP) and obtain an informed consent. The nurse is preparing a client for the termination phase of the nurse- client relationship. Which task should the nurse appropriately plan for during this phase? - Correct AnswerAssist with making appropraite referrals The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? - Correct AnswerWeight loss A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? - Correct AnswerConversion disorder A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the Saunders PN Mental Health Review Questions & Answers with Verified Solutions nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? - Correct AnswerEscort the manic client to his or her room. The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? - Correct AnswerThe false belief that one is being singled out for harm by others A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? - Correct Answer"You understand that people fear for their children, but you're feeling unfairly treated?" The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and Saunders PN Mental Health Review Questions & Answers with Verified Solutions notes that the client is doing vigorous push-ups. Which nursing action is appropriate? - Correct AnswerInterrupt the client and offer to take her for a walk. Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply. - Correct Answer-Monitor vital signs -Provide a safe environment -Address hallucinations -Provide reality orientation The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder? - Correct AnswerObserve for excessive exercise. Saunders PN Mental Health Review Questions & Answers with Verified Solutions specifically associated with withdrawal from opioids? - Correct AnswerYawning, irritability, diaphoresis, cramps, and diarrhea The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? - Correct AnswerObserving rigid rules and regulations The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? - Correct Answer"You must be feeling all alone at this point." The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? - Correct AnswerAssigning the client to a room at the end of the hall to prevent disturbing the other clients Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? - Correct AnswerAssign a staff member to the client who will remain with him or her at all times. The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? - Correct AnswerExamine and treat the wound sites. An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must Correct Answer which questions? Select all that apply. - Correct Answer-Is it in the best interest of society? -Does its use violate the client's rights? -Is this therapy in the best interest of the client? Saunders PN Mental Health Review Questions & Answers with Verified Solutions The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply. - Correct Answer-Autocratic Leader -Democratic Leader -Laissez-Faire Leader The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. - Correct Answer-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice new skills in a relative environment The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply. - Correct Answer-Promoting self-care and independence -Facilitating communication of distressing thoughts and feelings Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply. - Correct Answer-Rigidity -Inflexibility -Repetitive thoughts -Ritualistic behavior The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply. - Correct Answer-Respond to stimuli -Conduct electrical impulses -Release chemicals called neurotransmitters Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse should expect to observe? Select all that apply. - Correct Answer-Apraxia -Aphasia -Agnosia -Hyperorality A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply. - Correct Answer-Depression -Substance Abuse -Adverse Childhood Events -PTSD Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply. - Correct Answer-Irritability -Hypertension -GI disturbances The nurse is admitting a victim abuse client to the mental health unit with a diagnosis of severe anxiety. The nurse notes which signs/symptoms that indicate it is difficult for the victim to talk about the situation? Select all that apply. - Correct Answer-Hesitation -Lack of eye contact -Using vague statements such as,... The nursing instructor is helping students learn about bioethics, which is the study of specific ethical questions that arise in health care. The instructor reviews with the students which basic principles of bioethics? Select all that apply. - Correct Answer-Autonomy Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply. - Correct Answer-A high achiever -Personality changes -Lanugo over the back and extremities A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply. - Correct Answer-Inability to think clearly -Inability to problem solve The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse Saunders PN Mental Health Review Questions & Answers with Verified Solutions needs to use when communicating with this client? Select all that apply. - Correct Answer-Refer to hallucinations as if they are real -Ask the client directly about the hallucinations -Watch the client for cues... -Address any underlying emotion, need, or them... A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply. - Correct Answer-Monitor airway -Notify the RN -Remain with the client to provide support -Administer the prescribed intramuscular antiparkinsonian medication The nurse in the mental health clinic hears a client yelling and threatening to hurt his sister. The nurse reports this episode to the mental health therapist. Which should the nurse anticipate the Saunders PN Mental Health Review Questions & Answers with Verified Solutions therapist to do? Select all that apply. - Correct Answer-Identify the specific person being threatened -Take appropriate action to protect the identified victim -Assess and predict the client's danger of violence toward another The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply. - Correct Answer-Punishment -Avoidance Training -Pairing of a maladaptive behavior A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic Saunders PN Mental Health Review Questions & Answers with Verified Solutions -Practicing a religion -Married over 10 years The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply. - Correct Answer-Document the refusal of medication -Notify the RN -Ask the client why he is refusing the medication Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply. - Correct Answer-Speak slowly -Use simple statements -Provide the client with high-calorie beverages Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply. - Correct Answer-Incoordination -Mental confusion -Muscle hyperirritability The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply. - Correct Answer-Client threatened to commit suicide -Client threatened to kidnap his spouse The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply. - Correct Answer-I hid my silverware from dinner last night Saunders PN Mental Health Review Questions & Answers with Verified Solutions -I know that by this time tomorrow all my troubles will be over The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply. - Correct Answer-Reinforce the client's problem-solving abilities -Assess "secondary gains" that the somatic illness provides the client. The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply. - Correct Answer- Request that the client perform undemanding, self-care tasks -Reinforce teaching the client techniques to maintain present reality -Assist the client to reestablish relationships w/ significant others The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this Saunders PN Mental Health Review Questions & Answers with Verified Solutions The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term? - Correct AnswerPsychodrama A client is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client? - Correct AnswerAmnesia of events occurring near the period of the therapy is common. The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal? - Correct AnswerDepression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which Saunders PN Mental Health Review Questions & Answers with Verified Solutions about a crisis response? - Correct AnswerA client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person. The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate? - Correct AnswerDevelops a relationship to help reduce the frequency of the delusions Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety? - Correct AnswerStay with the client until the medication becomes effective. The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion? - Correct Answer"I don't feel like hurting myself anymore." Saunders PN Mental Health Review Questions & Answers with Verified Solutions A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action? - Correct AnswerHas the client open the gift with the nurse present The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills? - Correct AnswerDriving under the influence (DUI) conviction resulted in a 1-year suspended license The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective? - Correct Answer"My friends and I went out to lunch today." The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate Saunders PN Mental Health Review Questions & Answers with Verified Solutions A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action? - Correct AnswerApproach the client quietly, take her to her room, and assist her in getting dressed. The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual? - Correct AnswerSibling stating, "I don't feel safe around my brother." A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client? - Correct AnswerThe client verbalizes stages of grief and plans to attend a community grief group. Saunders PN Mental Health Review Questions & Answers with Verified Solutions 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 least likely to be helpful to this client at this time? - Correct AnswerInitiate confinement measures. The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan? - Correct AnswerInformation regarding the location of shelters A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention? - Correct AnswerThe client shampoos and dries the hair, freeing it of all hair spray and creams. The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates Saunders PN Mental Health Review Questions & Answers with Verified Solutions herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate? - Correct AnswerEncourage the client to stay and ask the client what she is feeling. A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time? - Correct Answer"What is causing you to become agitated?" A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which therapeutic response to the client? - Correct Answer"It must be frightening to you. Has something made you feel that your food is poisoned?" A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that Saunders PN Mental Health Review Questions & Answers with Verified Solutions the next appropriate nursing action at this time? - Correct AnswerNotify the registered nurse (RN). The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse? - Correct Answer"What aspects of this situation are the most difficult for you?" The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care? - Correct AnswerProvide safety for both the client and other clients on the unit. A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She Saunders PN Mental Health Review Questions & Answers with Verified Solutions doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? - Correct Answer"It's okay to grieve and be angry with your daughter and anyone else for a time." A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which nursing action should the nurse do first? - Correct AnswerTake the client to a quiet room. The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate? - Correct AnswerOffer to assist the client to an examination room until the primary health care provider is notified.