Mental Health Assessment B, Complete Answers with reasoning, A Guide

Mental Health Practice Assessment B 2016 A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements ...

Mental Health Practice Assessment B 2016 A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make "It is not uncommon to feel angry toward yourself or others Reason: Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching "Take this medication with food Reason: Lithium can cause GI distress and should be taken with food. Recommended sodium intake 1500mg/day. Recommended 2000-3000ml/day fluids. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs A client who has severe Alzheimer's disease Reason: Alzheimer's clients are typically confused with memory difficulties, tend to wander and need ADL assistance. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan Identify the client's trigger foods Reason: Nurse should identify trigger foods that initiate the client's binge and assist the client to understand his thoughts and behavior that relate to the foood A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse A family where one or both parents witnessed intimate partner violence in the home as children Reason: Parents who witnessed intimate partner violence as a child are more likely to become abusive. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? Inform the client that her admission is confidential Reason: According to EBP, Nurse should inform client about confidentiality during orientation phase of nurse-client relationship A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent A 35-year-old client who has major depressive disorder Reason; Client who has major depressive disorder is capable of making health care decisions unless determined legally incompetent A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following Clang association Reason: Clang associations often rhymes or contains a string of words that can have the same beginning sound. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching Language delay Reason: typical manifestation A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take Ask the client what the voices are saying Reason: to determine if the pt or others are at risk for injury A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make "Let's talk about what is upsetting you” Reason: The nurse us acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first Discuss the importance of hair with the client Reason: anticipatory grieving begins with acknowledging the importance of the expected loss A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data Sodium level 125 mEq/l Reason: In the presence of low sodium levels, renal excretion of lithium is reduces and the client is at risk for lithium toxicity. A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD) Lack of interest in an upcoming holiday Reason: Child with PTSD will have negative moods and difficulty remembering aspects of the traumatic event. Child can also have a loss of interest or lack of participation in significant activities and events such as holidays. A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take Gathersuppliesfor endotracheal intubation Reason: alcohol toxicity findings is respiratory depression A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? A client who is experiencing delusions of persecution Reason: Client believes person in power is out to harm him. A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation Nonmaleficence Reason: Do no harm A nurse is reviewing the medication administration record for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects Acute dystonia Reason: Benztropine, an anticholinergic agent, to relieve acute dystonia which is an extrapyramidal adverse effect of chlopromazine A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include Attending a relapse prevention group several times each week Reason: most effective strategy for relapse prevention is a 12-step program, such as AA A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening Attention to body language Reason: Active listening involves identifying verbal and nonverbal communication by the client which includes attention to body language A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse "Succinylcholine is given to reduce muscle movements during therapy” Reason: Succinylcholine is a muscle-paralyzing agent. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team Giving away possession Reason: Giving away possessions indicates that this client is at greatest risk forsuicide A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? "If you do my homework for me, I won't bother you for the rest of the day” Reason: this is an example of manipulative behavior