Learning System, Mental Health 1Exam with complete solutions

As a nurse approaches a client with schizophrenia, the client looks at the nurse and says, "back off. Leave me alone." The client appears tense and is pacing rapidly. Which of the following is an appropriate nursing resp ...

As a nurse approaches a client with schizophrenia, the client looks at the nurse and says, "back off. Leave me alone." The client appears tense and is pacing rapidly. Which of the following is an appropriate nursing response? - ANSWER I will give you space as long as you control yourself. Id like to know what is causing you to feel so tense A nurse on a mental health care unit is providing care for a client diagnosed with schizophrenia. The client is experiencing delusional thinking. Which of the following defense mechanisms is the client using when making delusional statements - ANSWER Projection A client diagnosed with schizophrenia says to the nurse "they lied about me and are trying to poison my food" which of the following is a therapeutic nursing response? - ANSWER You're having very frightening thoughts A client is hospitalized with schizophrenia. During a conversation with the nurse the client seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which statement by the nurse would be appropriate at this time - ANSWER What were we discussing when you began to feel uncomfortable A nurse is caring for a client whose provider has prescribed fluphenazine decanoate (prolixin) 12.5 mg IM weekly. Available is prolixin 50mg per 2 ml. How many ml should nurse plan to admin each week - ANSWER 0.5 ml A nurse is caring for a client admitted for depression 1 week ago who was started on Paxil at the time of admission. The client states to the nurse "my family would be better off without me. Which of the following is an appropriate therapeutic response by the nurse - ANSWER You sound upset. Are you thinking of hurting yourself? The nurse should document that a client is experiencing mild anxiety when the nurse observes which of the following - ANSWER The client is extremely alert A nurse is caring for a college student at the campus mental health counseling center. The student comes to see the nurse after getting a low grade in a course, and spends the entire time blaming the teacher and complaining about the lack of help seminars. The nurse recognizes this behavior as an example of which of the following defense mechanisms - ANSWER Displacement A client in a long term care facility asks the nurse to telephone her husband and ask him if her remembered to pick up his suit at the cleaners. The nurse knows the clients husband died five years ago. Which of the following is an appropriate nursing response? - ANSWER You miss you're husband a lot don't you? A client is admitted to the psychiatric unit for depression. The nurse observes an improvement in the clients grooming when the client comes to breakfast freshly bathed wearing clean clothes and with combed hair. Which of the following is an appropriate therapeutic response by the nurse - ANSWER You look nice after your bath and shampoo While taking a health history from a client in the outpatient mental health clinic, a nurse observes that the client is persistent in making personal inquiries. Which of the following is the most therapeutic response - ANSWER Explain to the client that this time is for him A client who is bipolar states to the psychiatric nurse in the mental health outreach clinic, "I no longer take my medication because I like to feel manic". which of the following is an appropriate therapeutic response by the nurse - ANSWER You feel better when you don't take your medication? A client admitted to the hospital with abdominal pain and GI bleeding has a colonoscopy, and colon cancer is discovered. The provider comes tot the clients room, tells the client the diagnosis, discusses treatment options, and leaves. Shortly after, the nurse enters the room and the client begins yelling at the nurse stating "I have received lousy care here and no one cares about me". The nurse recognizes that the client is demonstrating the defense mechanism of - ANSWER Displacement A widow is brought to the clinic by her son, who found her at home crying. She said that she could not go on. He tells the nurse that when his father died six months earlier, and the family was amazed at his mothers fortitude during and immediately after the funeral. She did not cry or seem unduly upset. The nurse recognizes that his mother had previously dealt with her husbands death by using which defense mechanism - ANSWER Denial A nurse is caring for a client diagnosed with dementia. She should understand that the goal of reminiscence therapy in long term care facilities is to - ANSWER Share memories of the past experiences and events A nurse is caring for a client diagnoses with borderline personality disorder. The client becomes attached to one of the nurses and refuses to talk with any other staff members. The client says the other staff members are abusive and untrustworthy. The client is using which of the following defense mechanisms - ANSWER Splitting The spouse of a chronic alcoholic client says to the nurse " I told my husband I would leave if he did not get into treatment. Now that he is here, I feel differently. What can i do to help him?" which of the following is a therapeutic nursing response - ANSWER Tell me more about the kind of help you feel you are able to provide at this time A client with dementia says to the nurse, "everyone wants to kill me". Which of the following statements is an appropriate nursing response - ANSWER You are frightened. This is a hospital, and we are here to help A nurse is caring for a client diagnoses with disorganized schizophrenia. The client does not return a visitors greeting and instead lies down on the bed and curls up in the fetal position. Which of the following defense mechanisms is the client exhibiting - ANSWER Regression A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. At 3am the client runs to the nurses station and demands to see the therapist immediately. Which of the following responses by the nurse is appropriate - ANSWER You must be very upset about something to want to see your therapist in the middle of the night Which of the following is an important short term goal for a nurse to plan with a suicidal client - ANSWER Sign a contract pledging not to act on suicidal plans The nurse working with a depressed client notes that the client has not come to breakfast and finds the client still in bed in a nightshirt. The client tells the nurse "Im too sick to bother. Leave me alone and go help someone else who is worth your time" which of the following is an appropriate response by the nurse - ANSWER You sound very discouraged and hopeless today The nurse in the oncology unit provides support to the parents of a child newly diagnoses with a glioblastoma tumor of the brain. In planning care, the nurse understands the parents initial reaction to a potentially terminal illness in their child is - ANSWER Denial and disbelief A parent brings an 18 month old child to the ED. The child has sustained a fractured femur. Which of the following statements by the parent might make the nurse suspect child abuse - ANSWER My child was riding a bicycle and got the right foot caught in the spokes A client has been diagnoses with anorexia nervosa. The nurse would anticipate that this client will display which of the following - ANSWER A poor sense of self identity A female client is seen in the ED with ecchymosis of the trunk and face. Upon direct questioning by the nurse, The client admits to having been struck by her spouse. when offered information about shelters for battered women, the client declines stating "I could never leave my husband because of my kids" which of the following is ab appropriate nursing response - ANSWER I am concerned about your safety A client is admitted to the detoxification center for alcohol addiction. On the day after admin the client develops hand tremors and asks the nurse about them. Which of the following is an appropriate nursing response - ANSWER They will persist for a few days now that you are not drinking A nurse is working in a busy pediatric ED. In which of the following cases should the nurse maintain a high index of suspicion of abuse - ANSWER A 9 month old who reportedly nearly drowned after climbing into the tub and turning on the water A nurse receives a call on a crisis intervention hotline from a client who threatens to commit suicide. Which would be the most important question for the nurse to ask - ANSWER How will you carry out your plan A nurse should recognize that MRI procedures are generally contraindicated for clients who have a fear of which of the following - ANSWER Closed spaces While working with a client, a nurse unconsciously attributes negative feelings to the client and becomes antagonistic toward her. The nurse is demonstrating which of the following - ANSWER Countertransference A nurse is admitting an adolescent female to the psychiatric unit for observation related to clinical depression. After completing the admission assessment, the nurse should give greatest priority to which of the following findings - ANSWER The client gave her favorite necklace to her best friend A client diagnosed with borderline personality disorder has become attached to one of the nurses who calls in sick one day. When given this news, the client breaks a glass bottle and uses it to self inflict a deep scratch. After providing first aid, which of the following is a therapeutic nursing action in relation to the clients behavior - ANSWER Help the client verbalize her feelings and reasons for the acting out behavior A college junior comes to the campus health services with reports of severe epigastric distress, and the nurse discovers the client has suffered from severe bulimia since freshman year. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot control it". Which of the following is an appropriate therapeutic nursing response - ANSWER You are feeling helpless about changing this behavior? A nurse is caring for a client who is scheduled for a cardiac cath. When arriving for the procedure, the client reports waking that morning with butterflies in the stomach, a sense of restlessness, urinary frequency and some difficulty concentrating while driving to the hospital. The admitting nurse should assess the clients anxiety level as which of the following - ANSWER Moderate A client with hallucinations is admitted to the psychiatric unit. In the initial phase of establishing a therapeutic nurse client relationship, it would be appropriate for the nurse to explore which of the following - ANSWER Perception of the presenting problem A nurses neighbor has just found out that her teenage child has died in a motor vehicle crash. The neighbor is crying inconsolably. Which of the following is an appropriate therapeutic nursing response - ANSWER Sit silently with the client while he cries The nurse asks a client who is suicidal to make a safety contract. The client states to the nurse "I cannot make a safety contract, because I can't promise that I will not harm myself". In the nurses plan of care, which of the following initial actions is best to ensure this clients safety when implementing the plan of care - ANSWER Have staff member stay with the client at all times A client is admitted to the psychiatric unit following treatment in the ER for an intentional overdose ingestion. As the nurse performs the admission assessment, the client says "why would you want to waste your time on a worthless person like me?" which of the following is a therapeutic nursing response? - ANSWER I think you are worthwhile, and want to talk to you A nurse should assess that the client with the highest potential for suicide is the depressed client who states which of the following - ANSWER I have it all figured out. Everything is going to be okay now