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NUR 2488 Mental Health Nursing Exam 2

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 Question 1 1 out of 1 points You are the nurse responsible for assessing for extrapyramidal side effects in a patient who has been taking chlorpromazine. Which of the following may be side effects for this medication? (Select all that apply.) Akathisia Acute dystonia Tardive Dyskinesia Answer s: Amenorrhea Akathisia Acute dystonia Tardive Dyskinesia Response Feedback: Extrapyramidal side effects of the central nervous system include involuntary motor movements, resulting in possible dystonia, akathisia or dyskinesia. Amenorrhea is a possible side effect of chlorpromazine, but is not an extrapyramidal side effect.  Question 2 1 out of 1 points An adult with depression has been treated with medication and cognitive behavioral therapy. The patient now verbalizes that being passive and letting others make decisions for her contributed to the depression. What referrals could the nurse make to help this patient prevent recurrence of depression? Selected Answer: Social skills training Answers: Social skills training Use of complementary therapyRelaxation training classes Learning desensitization techniques Response Feedback : Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others. Use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity has been identified as a concern. Desensitization is used in treatment of phobias  Question 3 1 out of 1 points A patient with suicidal impulses is placed on the highest level of suicide precautions. Which measures should be incorporated into the plan of care by the nurse caring for the patient? (Select all that apply.) Selected Answers: Maintain arm’s-length distance, institute one-on-one nursing observation around the clock Allow no glass or metal on meal trays Remove all potentially harmful objects from the patient’s possession Answers: Maintain arm’s-length distance, institute one-on-one nursing observation around the clock Allow no glass or metal on meal trays Keep patient within visual range while awake, but only check every 15 to 30 minutes while the patient is sleeping Only check the patient’s whereabouts every 15 minutes and make frequent verbal contacts. Remove all potentially harmful objects from the patient’s possession Response Feedback : One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient’s possession are measures included in any-level suicide precautions. The remaining options are used in less stringent levels of suicide precautions.

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