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Exam 5: Mental Health

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Question 21

Multiple Choice

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The client admitted to the mental health unit with major depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today, the client appears in the dayroom dressed and well-groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?

A) Continue to monitor the client's behavior from a distance.
B) Document that the client is adapting to the unit and is feeling safe.
C) Notify the staff of these observations at the team meeting, which will begin in 3 hours.
D) Speak to the client personally about the nurse's observations, and ask if the client is thinking about suicide.

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Question 22

Multiple Choice

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In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which of the following subjects?

A) Facilitating behavioral change
B) Promoting self-esteem in the client
C) Establishing the parameters of the relationship
D) Promoting problem solving skills in the client

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Question 23

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A nurse in the emergency department is preparing to care for a female client who has just been sexually assaulted. Which of the following client behaviors would demonstrate denial?

The nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization. When the nurse enters the client's room,the client asks the nurse, "Could you ask the physician to let me have a pass for the weekend?" The nursing response that assists the client in achieving these goals is:

The postsurgical client with a history of heavy alcohol intake is at risk for delirium tremens (DTs) , which would be manifested by:

The nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that the priority of care at this time is which of the following?

The nurse is helping to conduct a group therapy session. During the session, a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action?

The nurse is preparing for the arrival of a new client at a drug abusers' residential treatment center and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is:

A client has been admitted to the inpatient psychiatric unit because the client has displayed violent behavior and is at risk for potentially harming others. Which of the following should the nurse avoid doing when caring for this client?

The nurse caring for the hospitalized client diagnosed with bulimia nervosa would closely monitor which of the following? Select all that apply.

A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing action at this time?

A client admitted to the mental health unit with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which of the following responses by the nurse would be therapeutic?

The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the physician immediately. The appropriate nursing intervention is which of the following?

A female client diagnosed with catatonic stupor is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?

The mental health nurse has been meeting with a client on a weekly basis and, over the past several weeks, the client has been consistently 15 minutes late. Which of the following nursing actions is appropriate regarding the client's lateness for the scheduled meetings?

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?

A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which of the following statements, if made by the student, indicates an understanding of the focus of this form of therapy?

An acutely depressed client is receiving cognitive-behavioral therapy. The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. Which of the following interventions would the nurse include? Select all that apply.

The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority?

The nurse will monitor the client with a history of heroin addiction for which of the following signs of heroin withdrawal?