Deck 48: Mental Illness

Question 1

Which of the following nursing interventions may be used for a client with potentially violent tendencies,to facilitate expression of anger in an adaptive,nonviolent manner?

A)anger control assistance
B)brief dynamic therapy
C)cognitive behavior therapy
D)psychotherapy

Answer 1

anger control assistance

Question 2

A nurse is teaching the parents of a teenage client,who is undergoing therapy after a suicide attempt,about the warning signs of potential adolescent suicide,which include:

A)withdrawal
B)reclaiming of possessions and gifts previously bestowed upon friends and loved ones
C)statements such as not being around much longer
D)increased interest in personal appearance and hygiene

Answer 2

statements such as not being around much longer

Question 3

What change,if any,should the nurse expect in the dietary patterns of a client who is clinically depressed?

A)either overeating or eating little to nothing
B)intake is decreased
C)intake is increased
D)none

Answer 3

either overeating or eating little to nothing

Question 4

In determining whether a client has dysthymic disorder or a major depressive disorder,which of these characteristics would be associated with the client who has dysthymic disorder?

A)The client feels depressed nearly all the time.
B)An actual physical imbalance is the cause.
C)It occurs more commonly than major depressive disorders.
D)It occurs more often in men than in women.

Question 5

A client admitted with post-traumatic stress disorder (PTSD)is having a flashback.What is MOST important for the nurse to remember to do during this episode?

A)Avoid touching the client during the flashback.
B)Note and record the episode's length of time and any key ideas expressed.
C)Restrain the client as soon as possible,and administer sedation as ordered.
D)Speak to the client in a soft,calm voice.

Question 6

In addition to flashbacks,clients with post-traumatic stress disorder (PTSD)may exhibit or report which of these signs or symptoms?

A)diminished startle response
B)insomnia
C)hallucinations
D)hypervigilant

Question 7

Which type of hallucination is the MOST serious because it often results in the client causing harm to him- or herself or others?

A)auditory
B)command
C)ideation
D)visual

Question 8

A client is to receive pharmacological intervention for anxiety on a long-term basis.Which of these medicines should be tried FIRST because of its lack of addiction potential?

A)lorazepam (Ativan)
B)buspirone hydrochloride (BuSpar)
C)clonazepam (Klonopin)
D)diazepam (Valium)

Question 9

A nurse is teaching a client about a complicated care regimen to follow upon discharge.The client appears distracted and cannot recall basic information reviewed yesterday.When the nurse asks the client to describe feelings about leaving the hospital,the client states,"There's just too much to learn.I know I'm going to get home and mess something up." The nurse recognizes that the client may be experiencing what level of anxiety?

A)mild
B)moderate
C)severe
D)panic

Question 10

When a nurse is developing a no-suicide contract with a client,which of these aspects MUST be considered?

A)To increase client accountability,ask the client to promise the nurse or another significant friend or family member to avoid self-harm.
B)To communicate belief in the client,establish a minimum time frame of at least 1 week for the first contract.
C)To make the agreement more official and binding,have the document typed,signed by the client,and notarized.
D)To decrease impulsive behavior,include a detailed plan of action with the names and phone numbers of persons to call and the number of the local suicide crisis hotline to call if experiencing suicidal thoughts.

Question 11

When caring for clients who have mental illness,the nurse's priority intervention are focused on:

A)client advocacy
B)client safety
C)medication administration
D)teaching

Question 12

In addition to depressed mood or loss of interest in previously enjoyable activities,to be diagnosed as having a major depressive episode a client must exhibit at least four other symptoms,such as:

A)changes in appetite or weight,sleep disturbance,fatigue,and feelings of worthlessness
B)flight of ideas,body aches,feeling empty,and overeating
C)suicidal ideations,threatening behavior,loss of control,and moderate anxiety
D)difficulty making decisions,hallucinations,hyperactivity,and irritability

Question 13

What are the MOST common types of hallucinations?

A)auditory and visual
B)olfactory and tactile
C)tactile and visual
D)visual and olfactory

Question 14

A client admitted for treatment of mental illness tells the nurse,"Little green men are coming after me." Which of these responses would be MOST therapeutic?

A)"You must know Martians are not real."
B)"I'm calling your doctor and reporting this break with reality."
C)"Don't you think the weather is nice today?"
D)"You think someone is coming after you?"

Question 15

Most hospital readmissions for the client who has schizophrenia are the result of which of these factors?

A)injuries caused by self-harming behaviors
B)noncompliance with the prescribed medication regimen
C)side effects of pharmacological therapies
D)worsening of symptoms despite medication and outpatient therapy

Question 16

Before initiating antidepressant therapy,the health care provider should order which of these tests for the client?

A)CAT scan
B)complete blood count
C)electrocardiogram
D)electrolyte panel

Question 17

A client who is taking lithium to control bipolar disorder should understand the need to have which of these done monthly?

A)complete blood count,bleeding time,and hepatic function studies
B)lithium tolerance test
C)serum lithium level
D)24-hour urine creatine clearance test

Question 18

A client has a nursing diagnosis of Risk for self-directed violence related to emotional status and suicidal plan.Which of these nursing interventions should be initiated FIRST?

A)determining if the client has a specific plan
B)assisting the client in developing a no-suicide contract
C)evaluating the degree of risk associated with the client's verbalization of suicide intent
D)notifying the health care provider of the client's intention and current condition

Question 19

When a client has thoughts of hurting or killing him- or herself but may or may not plan to act on these thoughts,the client is considered to be:

A)actively suicidal
B)experiencing suicidal ideations
C)homicidal
D)manic-depressive

Question 20

When a nurse is teaching a client for whom Parnate,a monoamine oxidase inhibitor,has been prescribed,which of these instructions is essential?

A)Drink plenty of fluids.
B)Get at least 8 hours of sleep daily.
C)Do not take any medications unless they are prescribed by a health care provider.
D)The drug is contraindicated during pregnancy and breastfeeding.

Question 21

Which of these statements about elder abuse,neglect,or exploitation is TRUE?

A)Federal legislation has been enacted to protect older adults.
B)Documentation indicates elder abuse has been overreported.
C)The majority of abusers are family members.
D)Most of the abuse inflicted is physical in nature.

Question 22

Which of the following nursing behaviors is appropriate when interacting with a client who may have been the victim of interpersonal abuse?

A)Ask permission to call the client's family or friends.
B)Leave the client alone to sort out thoughts.
C)Place the client in a group setting.
D)React with surprise at the details the client reveals.

Question 23

A client who has ADHD experiences impaired social interaction with the peer group.Which of these nursing interventions is appropriate?

A)Allow the client to work out problems with peers unless help is requested.
B)Explain to the child those behaviors that are acceptable.
C)Limit the child's interactions with peers.
D)Reinforce any change in behavior.

Question 24

An older adult client has been taking lithium for several months.The nurse should recognize that the client's age increases susceptibility to which of these potential complications?

A)"breakthrough" episodes despite appropriate medical management
B)developing lithium toxicity
C)noncompliance with drug regime
D)sodium depletion

Question 25

A nurse suspects a 7-year-old client whose injuries are being treated is being physically abused.Which of these actions must the nurse take?

A)Discuss suspicions with the child's legal guardian prior to making any type of report.
B)Ensure that the appropriate state-designated agency is notified.
C)Notify the health care provider.
D)Notify the immediate nursing supervisor.

Question 26

Which of these statements about attention-deficit hyperactivity disorder (ADHD)is TRUE?

A)It is commonly associated with individuals who have been neglected by caregivers.
B)It usually disappears by adolescence.
C)It increases client sensitivity to the environment and surroundings.
D)It is evident when a client exhibits lack of attention.

Question 27

A client who is experiencing complications of anorexia nervosa has a nursing diagnosis of Fluid volume deficit related to inadequate intake of liquids,self-induced vomiting,laxative,and diuretic use.What is an appropriate nursing goal for this diagnosis?

A)The client's intake and output will be approximately equal by the 4th hospital day.
B)The client will demonstrate increased consumption of nutrients as evidenced by daily weight gain.
C)The client will verbalize feelings regarding the disease and coping strategies by the time of discharge.
D)The client will verbalize plans for the future.

Question 28

When a central nervous system stimulant such as Adderall is prescribed for a client who has attention-deficit hyperactivity disorder (ADHD),the nurse must instruct the client's parents to assess the medication's immediate effectiveness by looking for:

A)a paradoxical reaction
B)improved grades at school
C)increased activity level
D)increased insomnia and decreased appetite

Question 29

The nurse is caring for a client taking phenothiazine medications.The client teaching should include which of the following? (Select all that apply. )

A)Stop the medication if side effects occur.
B)Do not take other medications unless prescribed by your physician.
C)Decrease fluid intake to prevent the side effect of edema.
D)Wear sunscreen and protective clothing while outdoors.
E)Increase dietary fiber to prevent the side effect of constipation.
F)Do not drink alcohol while taking this medication.

Question 30

The nurse should monitor the client taking antipsychotic medications for which adverse reactions? (Select all that apply. )

A)arrhythmias
B)extrapyramidal side effect
C)fatal hypertensive crisis
D)neuroleptic malignant syndrome
E)tardive dyskinesia