A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client?
Do you hear voices
A female client with a history of drinking who was admitted 8 hours ago after receiving treatmetn for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action shoul
Ask client about alcohol quantity, frequency, and time of last drink
*Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit
I am here because the police thought I was doing something wrong
A female client on a psychiatric unit is sweating profusely while she vigorously does push ups and then runs the length of the corrider several times before crashing inot the furniture in the sitting room. Picking herself up, she begins to toss chairs asi
Risk for other related violence related to disruptive behavior
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. W
a sense of loss
What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks?
suicide ideation
A male adult comes to the mental health clinic and walks back and fourth in front of the offic door, but does not enter the office. He then walks arond a chair that is in the hallway several times before sitting down in the chair. What action should the n
observe the client in the chair
A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nures take
plan a list of activities to be carried out daily
*A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate
delusions of persecution
A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first
ask the client to identify problems that have occured during the last month
A 26 year old femal client has been particulary resteless and the nures finds her trying to leave the psychiatric unit. She tellsher the nurse," please let me leave because the secret police are after me." Which response is best for the nurse
come with me to your room and i will sit with you
The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued
Benztropine (Cogentin)
A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship
explore the client's feelings related to discharge
A female high school teacher who was a child of alcholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator
becomes the faculty sponsor for students against druin driving (SADD)
*A male client arrives at the mental health clinc and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assesment findings with the healthcare provider, a serum creatinine is obtained. What
Lithium is excreted by the kidneys and creatinine is related to kidney functioning
*The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding
remain alcohol free for 12 hours prior to the first dose
How do you take antabuse
each morning beginning 48 hours after your last drink of alcohol
When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide
all clients are screened for domestic abuse because it is common in our society
A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement
consult with the healthcare provider about reducing the dosage
schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit
current vital signs
*A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care
delay business decisions until his mania subsides
one on one session and nurse begins to get angry at patient
terminate session
*patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contant healthcare provider before giving
acetaminophen
teenaged girl self induced vomiting
frequency of binging and purging behaviors
antidepressant side effects
dry mouth, blurred vision, constipation
no TV in room tell patient
it is important to be out of your room and talking to others
An woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?
Lorazepam (Ativan) 8 mg PO HS
A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
do not take any over the counter meds
patient being discharged
discuss feelings of discharge
The nurse documents the mental status of a female client who has been hospitalized for several days by court order, The client states, "I don't need to be here" and tells the nurse that she believes that the television talks tp her. The nurse should docum
insight and judgement
depressed mother and daughter speaks in group
i hear you say you worry about your mother's distress
A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
establish trust by providing a calm, safe environment
When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't
Have the feelings associated with these events brought you to the clinic?
ECT therapy non responsive
have you taken erectile dysfunction meds
*adolescent teen interupts group about pets at home during group therapy. Best Nurse action?
redirect him with handout
client in bed all weekend, depression
get client out of bed and active
postpartum depression Sign & Symptoms (3)
distrubed sleep, sadness, poor concentration
*Pt scheduled for ECT. appropriate nurse action?
NPO after midnight
Pt believes that other group members are stealing his clothes.
encourage client to actively participate in activity
heatlh assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN
pancreatitis
knee surgery post op and diaphoretic and visual hallucinations
obtain vital signs
*A client is admitted for aspiration of material related to suicide. What is the nurse highest priority?
Risk for ineffective breathing pattern
A 38 year old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurs
I'll leave your tray here. I am available if you need anything else.
During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take?
Terminate the session before the feelings escalate.
*A MHW mental health worker is caring for a client with escalating aggression behavior, what action by the MHW warrants immediate intervention by the nurse
attempting to physically restrain the client
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?
Explain the nurse's role to the client.
client treated with lithium for bipolar develops diarrhea, vomiting and drowsiness, what action should the nurse do?
Notify HCP of the symptoms prior to the next admin of the drug
Pt has been discharged after denying suicidal thoughts to HCP. Pt mutters under his breath "Now I can kill my self" Best next action by the nurse.
Notify HCP immediately
Desirable outcome for a patient who had a combative episode at the grocery store with a sales clerk.
Patient will be able to identify triggers leading up to incident
Statement made by spouse of an alcoholic that indicates codependency.
Relapse was caused by a stressful event happen before episode."
(making excuses)
pt tells nurse he wants to kill his supervisor, nurse tells HCP, HCP tells SUpervisore. What disaplinary actions may be needed?
No actions needed. Everyone did appropriate jobs
Pt is mad at mom for turning him in. Wants mom to bring belongings but does not want to talk to her. Intervention the nurse should preform before visitation is?
discuss methods of clearly communicating
*Bulemic patient presents with eroded tooth enamel, severe chest and abdominal pain, mentions heartburn was presen 2 weeks ago. What should nurse tend to first?
suicide risk
*Bipolar patient comes out of room in a revealing top, short skirt, and no under wear. What should nurse do?
assist the client back to her room and help her select appropriate clothing
*The nurse and client trade roles and nurse demonstrates the same [who avoids eye contact, talk softs and the nurse trade places. ] as patient. What is the importance of this technique?
Identify the way the client act
*Most important question asked to patient during initial Intake Interview?
...
*Finding expected in alcoholic patients?
Increased ptt
Increased Liver enzymes
Increased alcohol tolerance
Moments of memory loss during drinking events(Blackouts)
*Client makes a statement I feel like im going to die, what level of Anxiety is it?
moderate anxiety
*Pt with PSTD after rape. who is displaying detachment. Best actions by nurse?
...
*Patient has new onset of blindness. What would suggest a Conversion reaction?
No organic correlation to sumptoms
What might the initial treatment include for a client admitted to the hospital with a diagnosis of bulimia nervosa?
Blood work to evaluate electrolyte status. Replenishment of electrolytes and fluids as indicated, careful monitoring for evidence of vomiting.
*A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. the nurse notices needle marks on the clients arms & plans to observe for narcotic withdraw
Agitation, sweating, & abdominal cramps
*Intimate partner violence. Which finding of the injuries should the nurse include in documentation?
Photographs
*Native Ameriacn shows up to apointment 20 minutes late. What is the most appropriate action by nurse?
Continue the session with the time left availible
*Pt recently diagnosed with cancer is having family members preform tasks the the patient is capable of doing. What does the nurse think of this?
expected, as the client to a quiet area of the unit
*middle aged female no previous psychiatric history because her family described her having paranoid thoughts "i want to find out why these people are stalking me
it sounds like this experience is frightening you
*"i dont know, i just cant think" what activity should the nurse suggest
set daily goals in the community meeting
*chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room
may i sit for you for a while
*pt had recent suicide attempt after wife filed for divorce, loss of job, and friend moved away. Nurse interventions.
encourage activities that will allow him to take control over his environment
*schitzophrenic pt who hears voicestarts becoming agitated and is considered anoying to other group members. Best nurse action?
move the client to a more quiet area
*18 year old admitted for susspeted drug overdose. Most important information nurse to obtaine from friends/ family is?
The drug that was ingested
A male college student brings his roommate to the campus clinic because the roommate has been talking to someone who is not present. the client tells the nurse that the voices are saying , "Kill Kill", What question should the nurse ask the client next?
are you planning to obey the voices
College student anxiety?
Help client feel safe
*history of alcoholism admitted for detoxification; 6 mg of ativan what additional prescription administer immediately
vitamin B1 (thiamine)
*Pt refuses to take meds. defiantly sits in floor.
...
PTSD admitted to psychiatric unit, which intervention is most important for plan of care
provide a quiet room away from the recreational area
8 month old with profound mental and physcial disabilities
ask mother is she has ever thought about harming herself or her child
recurrent negative symptoms of chronic schizophrenia and medication risperdal. walks laterally contracted position, something has made his body contort
administer the prescribed anticholinergic benztropine (cogentin) for dystonia
bipolar disorder depakote for manic reactions. monitored for seizure
observe the client for a reduction in hyperexcitable bahaviors because the drug enhances cerebral inhibitory transmitters
*A client with Schizophrenia using echolalia is becoming annoying. What is the best intervention?
Escort them to their room
A client with tremors and auditory hallucination is dehydrated, confused. To ensure physiological needs
Monitor vital signs
*A schizophrenia client refuses to eat because he says the food was poisoned. What intervention should the nurse implement?
Give the client food in an unopened container
*A client is anxious because the sun is coming up the next day. What intervention is most important?
Remain calm...
*Major depression disorder.. increased insomnia, amotivational. What intervention is likely to be most effective?
Teach plan for structure activity
A client is admitted to the mental health unit & sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, & resists talking. What action should the nurse implement?
Attempt to ask the client simple questions
The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?
Nausea & vomiting
*The nurse interacts with a male client who is very depressed & slow to respond to questions. the nurse asks the client to explain how he feeling, but the client looks down at the table. What action would be best for the nurse to implement?
Return at a later time to talk
*A male client turns over a table in the dayroom of a psychiatric unit & threatens to throw a chair at another client. Which action is most important for the nurse to implement?
obtain staff assistance to help diffuse the escalating situation
*Pt with stress admits to taking care of her ex-husbands parents. What mechanism should the nurse include for this patient?
...
*pt refuses PO medication
...
patient seeing snakes
administer ativan
a male client is admitted to the er; overdose of benzodiazepine
administer narcan