Exam 7: Mental Health

The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal.  What is the best explanation for these clinical characteristics?

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running.  The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead.  I can't believe this is happening."  What is the bestresponse by the nurse?

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression).  The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks?

A client with moderate Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor.  Which of the following responses by the nurse are appropriate?  Select all that apply.

A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess.  The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide.  The client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance.  The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP).  What is the priority nursing diagnosis (ND) at this time?

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD).  In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment?

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions.  Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking?  Select all that apply.

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit.  Which of the following is the priority nursing diagnosis?

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type.  Which statement by the parent requires an intervention?

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours.  The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to.  The clinical manifestations exhibited by the client are known as:

The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances.  The parents ask the nurse if the client will develop schizophrenia.  What is the most appropriate response by the nurse?

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room.  Which of the following should the nurse include in the initial plan of care?  Select all that apply.

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning.  When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty."  What is the best nursing action?

The nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public.  Which of the following client statements demonstrate an improvement in coping?  Select all that apply.

A nurse is caring for a client who was admitted following a failed suicide attempt.  Which client statement is most concerning?

A nursing home client with major depressive disorder reports difficulty going to sleep until late at night.  The client gets up, paces the hallway, wrings the hands, and appears teary.  What interventions should be included in the client's nursing care plan?  Select all that apply.

The nurse is reviewing the records of an adolescent client.  Which findings suggest that the client may need referral for depression screening?  Select all that apply.

An elderly client at the end of life is visited by family members.  One begins to cry and asks the nurse, "Will you please stay for a few minutes?"  The nurse has other clients to care for as well.  Which statement by the nurse is the mosthelpful?

The clinic nurse reviews telephone messages left by 4 clients.  Which client is the priority to call back first?

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia.  The client has a history of physical violence.  Which intervention should the nurse implement at this time to prevent the client from becoming violent?