Exam 7: Mental Health

The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT).  What information given by the new nurse would cause the charge nurse to intervene?

A nurse is admitting a child and observes multiple irregular bruises.  Which action should the nurse take next?

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner.  The client is now shaking, hyperventilating, and having heart palpitations.  What is the priority nursing action?

A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer.  Which intervention would be the priority?

A client recently diagnosed with schizophrenia is hospitalized.  The client appears distraught and says to the nurse, "The voices are bad today…they are so angry with me."  Which of the following is the best response by the nurse?

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior.  The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client.  Without responding, the client stands up and starts to leave.  Which of the following actions is bestfor the nurse to take?

A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup.  Which is the most appropriate nursing action?

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse.  Sometimes I think my spouse is the one who should be here.  I can stop drinking any time I want."  The nurse recognizes that the client is exhibiting which of the following defense mechanisms?

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train.  The nurse recognizes that this client most likely suffers from which psychological disorder?

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis.  The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this."  How should the nurse respond?

The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver.  Which observations would cause the nurse to suspect neglect?  Select all that apply.

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home.  What is the most important strategy for the nurse to include in the instruction?

Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode?  Select all that apply.

The nurse cares for a client who just had surgical excision and biopsy of a tumor.  The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider.  The client asks the nurse, "Am I going to die?"  Which statement by the nurse is appropriate?

The home health nurse assesses a child and suspects that the child is being abused.  Which of the following questions are appropriate for the nurse to ask the caregiver?  Select all that apply.

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder.  Which assessments would support this diagnosis?  Select all that apply.

The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care.  The spouse states, "I don't think I can make this decision right now.  What would you do?"  How should the nurse respond?

The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs.  When questioned about the bruises the child begins to cry and states, "Somebody did things to me."  Which of the following communications by the nurse is appropriate?  Select all that apply.

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility.  When the nurse finds the client wandering at night, which of the following statements is most appropriate?

A client with moderate Alzheimer disease is started on memantine.  In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following?