Exam 7: Mental Health

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder.  The nurse identifies which dinner selection as the most appropriate to promote client nutrition?

Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques?

A young client is diagnosed with major depressive disorder.  Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly."  During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement.  I look awful and I'm not much good for anything."  What is the best response by the nurse?

A child with a high level of school absenteeism has been determined to have school phobia.  The school nurse should counsel the child's parent/caregiver to take which action?

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa.  After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me?  I'm fatter and uglier than ever."  What is the best action by the nurse?

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa.  Which interventions would be included in the plan of care?  Select all that apply.

A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital.  The client returned to the unit 15 minutes past curfew and did not sign in.  The next day, this behavior is brought up in a group meeting.  The client says, "It's all the nurse's fault.  The nurse was right there and did not remind me to sign in."  What is the best response by the nurse?

A client presents to the emergency department with alcohol intoxication.  Assessment shows nystagmus, ataxia, and confusion.  The client's breath smells of alcohol.  Which prescription from the health care provider should the nurse implement first?

A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam.  The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die.  You cannot stop me."  When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment.  Why can't they just give my spouse medication?"  Which is the best response by the nurse?

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication.  The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person.  The client says, "Everyone tells me that the voices are not real, but they are driving me crazy."  What is the best action by the nurse?

The emergency department registered nurse is triaging a client for the risk of suicide.  The client had thoughts of self-injury yesterday but is not sure today.  Which of the following would be considered a known risk factor for suicide in this client?  Select all that apply.

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD).  She says to the nurse, "It's all my fault.  I should have known not to accept a drink from someone I just met in a bar."  What is the best response by the nurse?

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate?

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia.  Which assessment finding is most consistent with the diagnosis of delirium?

The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy.  The nurse suspects delirium tremens based on which assessment data?  Select all that apply.

Which clinical manifestations would the nurse identify with severe anorexia nervosa?  Select all that apply.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder.  Which statements by the spouse indicate codependence?  Select all that apply.

The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration.  The client's spouse is at the bedside and appears angry.  Which action is the priority at this time?

The mental health clinic nurse is evaluating the treatment plan for a client with obsessive-compulsive disorder who counts backward from 5 to 1 many times a day.  Which of the following client statements indicates progress toward effective coping?  Select all that apply.