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1. A client is Prescribed Risperidone (Risperdal) for schizophrenia. Which Side Effects Should the nurse report to the Health Provider? 2. A homeless women who is well-educated and has chronic sc... hizophrenia is admitted to the mental health unit when found by the police walking in the middle of the street. The client presents with strong body odor, dirty clothes and avoliation. After a week of neurolepticdrug therapy drug therapy, the client discusses with the nurse her thoughts about bathing. Which statement suggest that the client is progressing? 3. A young adult with eroded tooth enamel presents to the clinic with multiple complaints including severe pain in the chest and upper abdomen that occurred when the client induced vomiting after eating a large breakfast. The client also reports severe hearthburn in the last week and describes a history of taking laxatives and eating prunes whenever overeating. What client problem should address first? 4. A young adult male receives a prescription for disulfiram to help maintain abstinence from alcohol. What information should the nurse include in a teaching plan for this client? 5. A older male resident of a long-term care facility who is chronically depressed. Has become more reclusive and refuses to leave his room today. His family moved away from a local area and they are unable to visit as much as they did in the past. Which comment by the nurse is likely to be most helpful to this client? 6. The nurse develops a plan of care for a female client who scratches her wrist in attempt to deal with anxiety. Which client outcome is most important to include in the plan of care. 7. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? 8. An adolescent male client is hospitalized after he threatened a teacher in school. He admits feeling angry because his mother tricked him and brought him tp the hospital . The client steates that when his mother visits, he plans to her his belonging from her, but is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? 9. The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder? 10. A client diagnosed with schizophrenia looks frightened and tells the nurse. “ I keep hearing the voices telling me to hurt somebody. Don’t you hear them? Which response is the best for the nurse to provide? 11. During admissions assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of the shooting the supervisor. The client asks the nurse not to revel this to anyone else. The nurse immediately notifies the clients therapist and other team members of the client’s thoughts. The therapist then calls the client’s supervisors and shares the client’s thoughts about shooting the supervisors. what outcome is appropriate based on the action of the nurses? 12. When implementing a therapeutic on a psychiatric unit, which intervention is most important for the nurse to implement. 13. The RNurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? 14. A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first 15. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem? 16. When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her back and upper arms. The child's aunt tells the nurse that the child's parents abuse drugs and alcohol. What intervention is most essential for the nurse to implement? Assement 17. A male client with a long history of alcohol dependency arrives in the Emergency Department describing the feeling of bugs crawling on his body. His blood pressure is 170/102 , pulse rate is 110 beats/minute, and blood alcohol level (BAL) is 0mg / (dL) . Which prescription should the nurse administer? 18. A client on the mental health unit is becoming more agitated, shouting at the stali, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? 19. A middle-aged remale client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse “I want to find out why these people are stalking me” which response should the nurse provide? 20. Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? 21. A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response is best for the nurse to provide this client? 22. A young adult male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating from high school next month, and he tells the school nurse that wants to live away from home for college. What info is most important for the nurse to provide the client and his family? 23. . A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? 24. A client is discussing feeling related to recent loss with the nurse. The nurse remains silent when the client says, “ I don’t know how I will gone” wha is the most likely reason for the nurse’s behavior? 25. A successful businessman presents to the community mental health center caining of sleeplessness and axiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? 26. The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time 27. The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measures should the nurse emphasize for the client’s recovery 28. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately 29. During a high school class on substance abuse, a student tells the group. “ If I tried cocaine, I know I could handle it. I know when to stop.” What response is best for the nurse to provide. 30. What is the most important goal or a client with major depression who has been receiving an antidepressant medication for two weeks?. 31. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which actions is the most important for the nurse to implement. 32. The nurse is using the cage questionnaire as a screening tool for a client s seeking whelp because his life said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool. 33. The nurse interacts with a male client who is very depressed and slow to respond to questions. The nurse asks the client to explain how he is feeling, but the client looks down at the table. What action would be best for the nurse to implement? 34. A male with alcohol dependene is admitted to the hospital with abdominal pain. What it intervention should the nurse implement? 35. An adult female is brought to the emergency center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. What info best supports this problem. 36. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? 37. After meeting with health provider, a client who is diagnosed with bipolar disorder screaming and stomping both feeile pacing the hallway What action should the nurse take? 38. A client is admitted to the mental health unit and sit un the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious and resists talking. What action should the nurse implement. 39. A recently widowed middle-aged female client presents to the psychiatric for evaluation and tells the nurse that she has “little to live” she describes one previous suicidal and to help ensure client safety, which action is best for the nurse to implement? 40. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first? 41. A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority? 42. A male Native-American client diagnosed with depression is 20 min late for an appointment with the psychiatric nurse is an outpatient clinic. Which action should the nurse take. 43. The nurse is taking history of any young adult who is 5 feet 3 inches tall weights 90 pounds. Which reported finding is most important for the nurse to address immediately 44. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations? 45. On admission to the mental health unit, a client with schizophrenia tells the nurse that he is the son of God. Based on this statement ehich intervention should the nurse include in this client’s plan of care. 46. Which client statement suggest to the nurse that is using a defense mechanism of projection to deal with anxiety relates to admission to a psychiatric unit? 47. While caring for an older client, the RN observes multiple bruises Over the client’s legs, arms, back, and gluteal areas. When the client.Contact, the RN suspects elder abuse. What action should the RN take? 48. The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? 49. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take? 50. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeterias part of the school’s work study program. What action should the nurse take? 51. A male client comes to the emergency center he has an erection that will no resolve the client reports that he is taking trazodone (desyrel) for insomnia which information is most important for the nurse to ask this client? 52. On admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. Based on this statement, which intervention should the RN include in this client’s plan of care? 53. The nurse on the day shift receives report about a client with depression who w the weekend. The nurse walks into the client’s room in the morning and finds the what intervention is best for the nurse to implement? 54. Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? 55. A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? 56. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client’s behavior? 57. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? 58. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? 59. A female client engages in repeated checks of door and a window lock behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? 60. A female client with obsessive-compulsive disorder is admitted to the hospital for a cardiac catherization. The afternoon before the procedures, the client begins to kepp detailed notes of the nursing care she is receiving, and reports her finding to the nurse at bedtime. What action should the nurse implement. 61. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. 62. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confuse. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem? 63. The occupational health nurse is working with a female employee who just notified that her child was involved in a motor vehicle collision and taken to the hospital. The employee states,” I can’t believe this. What should I do? Which response is the best fo r the nurse to provide in this crisis? 64. A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit? 65. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing? 66. While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique? 67. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? 68. When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? 69. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? 70. The nurse is leading group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase in the group development? 71. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement. 72. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? 73. The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? 74. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? 75. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN? 76. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? 77. . When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? 78. . When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? 79. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? 80. The mother of an 8 month old infant with profound mental and physical disabilities tells the nurse how depressed she is because she is because she realizes that her chilf will never achieve normal growth and development milestones. How should the nurse respond to this mother? 81. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? 82. A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? A. Purchase a gun to use for protection 83. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? 84. A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? 85. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? 86. The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement? 87. A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? 88. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit 89. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client’s current feelings of depression? 90. The nurse documents the mental status of a female client who has been hospitalized for several days by court order. The client state, “I don’t need to be here” and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? 91. An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? 92. The nurse complete an assessment of a client who is experiencing intimate partner violence (IPV) which finding of the injuries should the nurse include in the documentation? [Show More]

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