RN Mental Health 2019 With NGN
Total Questions : 69
Showing 25 questions, Sign in for moreA nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
Explanation
Planning a menu with the client helps to establish a regular eating pattern and promotes a sense of control and autonomy. Weighing the client every other day may increase anxiety and trigger bingeing. Remaining with the client for 1 hr after meals may be perceived as punitive and intrusive. Offering snacks when the client is hungry may reinforce bingeing behavior.
A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?
Explanation
The client's statement reflects a realistic and positive attitude toward recovery and a decrease in perfectionism, which is a common trait among clients with anorexia nervosa. Following cooking blogs may indicate an unhealthy obsession with food and calories. A BMI of 14 is still below the normal range of 18.5 to 24.9 and indicates severe malnutrition. A potassium level of 3.2 mEq/L is below the normal range of 3.5 to 5.0 mEq/L and indicates electrolyte imbalance.
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
Explanation
The client's statement reflects a loss of interest and pleasure in life, which is a major symptom of clinical depression. The other statements are normal expressions of grief that do not necessarily indicate depression, although they may warrant further assessment and support from the nurse.
A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?
Explanation
The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.
A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?
Explanation
A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.
A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan?
Explanation
Referring the client to a self-help group, such as Alcoholics Anonymous (AA), is an effective strategy to promote sobriety and prevent relapse after discharge. Self-help groups provide peer support, education, and coping skills for clients who have alcohol use disorder. Systematic desensitization is a behavioral therapy technique that is used to treat phobias, not alcohol use disorder. Contacting a close relative of the client may be helpful, but it is not a recommendation that the nurse can make without the client's consent and involvement. Buprenorphine is a medication that is used to treat opioid use disorder, not alcohol use disorder.
A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?
Explanation
The nurse should obtain a prescription for the restraints within 2 hr of initiating them, as this is a legal requirement and ensures that the restraints are used appropriately and safely. The other options are also important, but they are not the priority action in this situation.
A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates accurate understanding of this medication's effects?
Explanation
Methylphenidate is a stimulant medication that helps improve attention, focus, and impulse control in clients with ADHD. It does not cause weight gain, drowsiness, or relaxation as side effects.
A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
Explanation
The nurse should provide a trained advocate to stay with the client, as this can help reduce the psychological trauma and provide emotional support and information to the client. The other options are also important, but they can be done later or after obtaining the client's consent.
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
Explanation
Thought stopping technique is a cognitive-behavioral intervention that aims to interrupt and replace unwanted thoughts with more adaptive ones. Snapping a rubber band on the wrist is a form of aversive conditioning that creates a negative association with the obsessive thought and reduces its frequency and intensity.
A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
Explanation
The nurse manager should follow the principle of least restrictive intervention when dealing with a client who is agitated and refuses treatment. The first step is to attempt verbal de-escalation by using calm, respectful, and empathetic communication, and offering choices and alternatives to the client. This may help reduce the client's anxiety and resistance, and increase their cooperation and trust.
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?
Explanation
Alcohol withdrawal syndrome is characterized by autonomic hyperactivity, which can manifest as tachycardia, hypertension, hyperthermia, diaphoresis, tremors, seizures, and delirium tremens. The nurse should monitor the client's vital signs, provide supportive care, and administer medications as prescribed to prevent complications and promote recovery.
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
Explanation
Delirium is an acute confusional state that can have various causes, such as infection, medication, or metabolic imbalance. It is characterized by a sudden onset of altered mental status, fluctuating levels of consciousness, disorientation, and perceptual disturbances.
A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?
Explanation
This response demonstrates empathy and respect for the client's feelings, and encourages the client to explore and express his or her emotions. It also allows the nurse to assess the client's situation and provide appropriate support and interventions.
A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?
Explanation
The priority for the nurse is to ensure safety for the client and others in the facility. Asking the client about his or her intentions can help the nurse determine the level of risk and plan appropriate interventions, such as setting limits, providing supervision, or initiating seclusion or restraint if necessary.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
Explanation
The client is transferring his anger toward his partner to the nurse, who is a less threatening person.
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?
Explanation
Alzheimer's disease causes progressive cognitive impairment, which affects memory, language, and visual-spatial skills.
A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?
Explanation
Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if taken with selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine.
A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?
Explanation
The nurse should have the provider assess the client within 1 hr after applying restraints to ensure that the restraints are necessary and appropriate, and to monitor the client's physical and mental status.
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?
Explanation
The nurse can delegate basic care tasks such as assisting with ambulation to an assistive personnel, as long as they are trained and supervised. The other tasks require nursing judgment or knowledge and should not be delegated.
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
Explanation
The nurse should respect and document the client's right to refuse treatment, even if he was involuntarily committed, unless there is a court order for ECT. The nurse should not coerce, misinform, or pressure the client to receive ECT against his will. 22.
A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
Explanation
The nurse should first establish a rapport with the client to promote a therapeutic relationship and create a safe environment. This will help the client feel more comfortable and willing to share their feelings and concerns. The other actions are also important, but they are not the priority.
A nurse is caring for a school-age child who has a new diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?
Explanation
Methylphenidate is a stimulant medication that is commonly used to treat attention-deficit hyperactivity disorder in children and adults. It helps improve attention, focus, and impulse control by increasing dopamine and norepinephrine levels in the brain. The other medications are not indicated for this condition.
A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
Explanation
A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Explanation
The nurse should collaborate with the client to set realistic and achievable goals for weight gain and recovery. This can help increase the client's sense of control and motivation. The other options are not appropriate because they do not involve the client in the decision-making process, and they may increase the client's resistance or anxiety.
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