PSYCHIATRIC AND MENTAL HEALTH
NURSING
1. Heart rate of 120 to 140 beats/minute - ✅✅ -"Which assessment finding
is most consistent with early alcohol withdrawal?
✅✅
2. One who plans a violent death and has the means readily available -
-"Which client is at highest risk for suicide?
✅✅
"3. ""I just can't seem to get down to the weight I want to be. I'm so fat
compared to other girls."" - -A 15-year-old client is brought to the
clinic by her mother. Her mother expresses concern about her daughter's
weight loss and constant dieting. The nurse conducts a health history
interview. Which of the following comments indicates that the client may be
suffering from anorexia nervosa?
4. euphoria and constricted pupils. -✅✅ -The nurse is caring for a client
who has been abusing opiates. Data collection findings in a client abusing
opiates such as morphine include:
4. Excessive and ritualized exercise" - ✅✅ -The nurse is caring for an
adolescent female who reports amenorrhea, weight loss, and depression.
Which additional data collection finding would suggest that the woman has
an eating disorder?
✅✅
"2. Establish a trusting relationship with the client. - -A client is
admitted to the psychiatric unit with a diagnosis of anorexia nervosa.
Although she is 5' 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks
incessantly about how fat she is. Which approach should the nurse take
first when caring for this client?
✅✅
"4. Evaluating exercise activities - -"Which task is most important
when developing a plan of care for a client with anorexia nervosa?
,1. client functions well in other areas of his life 2. The degree of
aggressiveness is out of proportion to the stressor. 4. The client has a
✅✅
history of parental alcoholism and a chaotic, abusive family life. -
-While collecting data on a client who was diagnosed with impulse
control disorder (and who displays violent, aggressive, and assaultive
behavior), the nurse can expect to find which of the following
assessments?
"Please go to bed now. We'll talk in the morning." - ✅✅ -A client with a
history of alcoholism returns to the hospital 3 hours later than the time
specified on his day pass. His breath smells of alcohol and his gait is
unsteady. What should the nurse say?
"4. Diaphoresis, tremors, and nervousness - ✅✅
-A client voluntarily
admits himself to the substance abuse unit. He confesses that he drinks 1
qt or more of vodka each day. Later that afternoon, he begins to show signs
of alcohol withdrawal. What are some early signs of this condition?
"3. The client keeps a journal and discusses it with the nurse. - ✅✅ -One
of the goals for a client with anorexia nervosa is that the client will
demonstrate increased coping by responding to stress in constructive
ways. Which of the following actions is a positive indicator that the client is
working toward meeting the goal?
✅✅
"4. Arranging for a presentation by a local teenager who was involved in an
alcohol-related traffic fatality - -A local high school recently identified a
problem with alcohol-related accidents among student drivers; two of these
accidents resulted in death. School officials developed a plan to address
the problem. The school nurse begins her part by addressing primary
prevention. Which intervention by the school nurse is appropriate?
✅✅
"4. ""I know it's important for you to feel in control, but I'll monitor you for 90
minutes after you eat."" - -During postprandial monitoring, a client with
bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting
,your time. After you sat with me yesterday, I was still able to purge. Today,
my goal is to do it twice." What is the nurse's best response?
3. identify anxiety-causing situations. - ✅✅
-The nurse is caring for a client
diagnosed with bulimia. The most appropriate initial goal for a client
diagnosed with bulimia is to:
"1. Al-Anon - ✅✅ -A client is being treated for alcoholism. After a family
meeting, the client's spouse asks the nurse about ways to help the family
deal with the effects of alcoholism. The nurse should suggest that the
family join which organization?
"3. jointly by the client and nurse. -✅✅ -A client is admitted to the
inpatient adolescent unit after being arrested for attempting to sell cocaine
to an undercover police officer. The nurse assists in writing a behavioral
contract. To best promote compliance, the contract should be written:
✅✅
"3. Providing a quiet environment and administering medication as needed
and prescribed - -A client begins to experience alcoholic hallucinosis.
What is the appropriate nursing intervention at this time?
✅✅
"2. ""You made a very difficult decision. I'll be here if you want to talk."" -
-A nurse is caring for a client who just separated from her husband
because of his alcohol abuse problem. Which statement by the nurse
conveys empathy?
"2. total abstinence. -✅✅ -A client has approached the nurse asking for
advice on how to deal with his alcohol addiction. The nurse should tell the
client that the only completely effective treatment for alcoholism is:
1. Establish a contract with the client that specifies the amounts and types
✅✅
of food she must eat at each meal. 4. Reward the client for satisfactory
weight gain. - -Which nursing interventions should be included in the
treatment plan of a client diagnosed with bulimia nervosa?
, "2. Rejection by peers -✅✅ -Which psychosocial influence has been
causally related to the development of aggressive behavior and conduct
disorder?
✅✅
"2. Client's safety needs - -"When planning care for a client who has
ingested phencyclidine (PCP), which of the following is the highest priority?
"2. begin anytime within the next 1 to 2 days. -✅✅ -A client is being
admitted to the substance abuse unit for alcohol detoxification. As part of
the intake interview, the nurse asks him when he had his last alcoholic
drink. He says that he had his last drink 6 hours before admission. Based
on this response, the nurse should expect early withdrawal symptoms to:
"2. alcohol withdrawal. -✅✅ -Eighteen hours after undergoing an
emergency appendectomy, a client with a reported history of social drinking
displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126
beats/minute; respiratory rate, 24 breaths/minute; and blood pressure,
140/96 mm Hg. The client exhibits gross hand tremors and is screaming for
someone to kill the bugs in the bed. The nurse should suspect:
✅✅
"3. ""I'm going to take 1 day at a time. I'm not making any promises."" -
-After completing chemical detoxification and a 12-step program to
treat drug addiction, a client is being prepared for discharge. Which remark
by the client indicates a realistic view of the future?
3. Imbalanced nutrition: Less than body requirements - ✅✅ -"Which
nursing diagnosis takes priority for a client diagnosed with anorexia
nervosa?
"3. domestic violence and abuse span all socioeconomic classes. - ✅✅ -A
client is brought to the emergency department after being beaten by her
husband, a prominent attorney. The nurse caring for this client understands
that:
NURSING
1. Heart rate of 120 to 140 beats/minute - ✅✅ -"Which assessment finding
is most consistent with early alcohol withdrawal?
✅✅
2. One who plans a violent death and has the means readily available -
-"Which client is at highest risk for suicide?
✅✅
"3. ""I just can't seem to get down to the weight I want to be. I'm so fat
compared to other girls."" - -A 15-year-old client is brought to the
clinic by her mother. Her mother expresses concern about her daughter's
weight loss and constant dieting. The nurse conducts a health history
interview. Which of the following comments indicates that the client may be
suffering from anorexia nervosa?
4. euphoria and constricted pupils. -✅✅ -The nurse is caring for a client
who has been abusing opiates. Data collection findings in a client abusing
opiates such as morphine include:
4. Excessive and ritualized exercise" - ✅✅ -The nurse is caring for an
adolescent female who reports amenorrhea, weight loss, and depression.
Which additional data collection finding would suggest that the woman has
an eating disorder?
✅✅
"2. Establish a trusting relationship with the client. - -A client is
admitted to the psychiatric unit with a diagnosis of anorexia nervosa.
Although she is 5' 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks
incessantly about how fat she is. Which approach should the nurse take
first when caring for this client?
✅✅
"4. Evaluating exercise activities - -"Which task is most important
when developing a plan of care for a client with anorexia nervosa?
,1. client functions well in other areas of his life 2. The degree of
aggressiveness is out of proportion to the stressor. 4. The client has a
✅✅
history of parental alcoholism and a chaotic, abusive family life. -
-While collecting data on a client who was diagnosed with impulse
control disorder (and who displays violent, aggressive, and assaultive
behavior), the nurse can expect to find which of the following
assessments?
"Please go to bed now. We'll talk in the morning." - ✅✅ -A client with a
history of alcoholism returns to the hospital 3 hours later than the time
specified on his day pass. His breath smells of alcohol and his gait is
unsteady. What should the nurse say?
"4. Diaphoresis, tremors, and nervousness - ✅✅
-A client voluntarily
admits himself to the substance abuse unit. He confesses that he drinks 1
qt or more of vodka each day. Later that afternoon, he begins to show signs
of alcohol withdrawal. What are some early signs of this condition?
"3. The client keeps a journal and discusses it with the nurse. - ✅✅ -One
of the goals for a client with anorexia nervosa is that the client will
demonstrate increased coping by responding to stress in constructive
ways. Which of the following actions is a positive indicator that the client is
working toward meeting the goal?
✅✅
"4. Arranging for a presentation by a local teenager who was involved in an
alcohol-related traffic fatality - -A local high school recently identified a
problem with alcohol-related accidents among student drivers; two of these
accidents resulted in death. School officials developed a plan to address
the problem. The school nurse begins her part by addressing primary
prevention. Which intervention by the school nurse is appropriate?
✅✅
"4. ""I know it's important for you to feel in control, but I'll monitor you for 90
minutes after you eat."" - -During postprandial monitoring, a client with
bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting
,your time. After you sat with me yesterday, I was still able to purge. Today,
my goal is to do it twice." What is the nurse's best response?
3. identify anxiety-causing situations. - ✅✅
-The nurse is caring for a client
diagnosed with bulimia. The most appropriate initial goal for a client
diagnosed with bulimia is to:
"1. Al-Anon - ✅✅ -A client is being treated for alcoholism. After a family
meeting, the client's spouse asks the nurse about ways to help the family
deal with the effects of alcoholism. The nurse should suggest that the
family join which organization?
"3. jointly by the client and nurse. -✅✅ -A client is admitted to the
inpatient adolescent unit after being arrested for attempting to sell cocaine
to an undercover police officer. The nurse assists in writing a behavioral
contract. To best promote compliance, the contract should be written:
✅✅
"3. Providing a quiet environment and administering medication as needed
and prescribed - -A client begins to experience alcoholic hallucinosis.
What is the appropriate nursing intervention at this time?
✅✅
"2. ""You made a very difficult decision. I'll be here if you want to talk."" -
-A nurse is caring for a client who just separated from her husband
because of his alcohol abuse problem. Which statement by the nurse
conveys empathy?
"2. total abstinence. -✅✅ -A client has approached the nurse asking for
advice on how to deal with his alcohol addiction. The nurse should tell the
client that the only completely effective treatment for alcoholism is:
1. Establish a contract with the client that specifies the amounts and types
✅✅
of food she must eat at each meal. 4. Reward the client for satisfactory
weight gain. - -Which nursing interventions should be included in the
treatment plan of a client diagnosed with bulimia nervosa?
, "2. Rejection by peers -✅✅ -Which psychosocial influence has been
causally related to the development of aggressive behavior and conduct
disorder?
✅✅
"2. Client's safety needs - -"When planning care for a client who has
ingested phencyclidine (PCP), which of the following is the highest priority?
"2. begin anytime within the next 1 to 2 days. -✅✅ -A client is being
admitted to the substance abuse unit for alcohol detoxification. As part of
the intake interview, the nurse asks him when he had his last alcoholic
drink. He says that he had his last drink 6 hours before admission. Based
on this response, the nurse should expect early withdrawal symptoms to:
"2. alcohol withdrawal. -✅✅ -Eighteen hours after undergoing an
emergency appendectomy, a client with a reported history of social drinking
displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126
beats/minute; respiratory rate, 24 breaths/minute; and blood pressure,
140/96 mm Hg. The client exhibits gross hand tremors and is screaming for
someone to kill the bugs in the bed. The nurse should suspect:
✅✅
"3. ""I'm going to take 1 day at a time. I'm not making any promises."" -
-After completing chemical detoxification and a 12-step program to
treat drug addiction, a client is being prepared for discharge. Which remark
by the client indicates a realistic view of the future?
3. Imbalanced nutrition: Less than body requirements - ✅✅ -"Which
nursing diagnosis takes priority for a client diagnosed with anorexia
nervosa?
"3. domestic violence and abuse span all socioeconomic classes. - ✅✅ -A
client is brought to the emergency department after being beaten by her
husband, a prominent attorney. The nurse caring for this client understands
that:
