PSYCHIATRIC AND MENTAL HEALTH NURSING

PSYCHIATRIC AND MENTAL HEALTH NURSING EXAM "Which assessment finding is most consistent with early alcohol withdrawal? 1. Heart rate of 120 to 140 beats/minute "Which client is at highest risk for suicide? 2. One who plans a violent death and has the means readily available 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? "3. ""I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls."" 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. euphoria and constricted pupils. 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? 4. Excessive and ritualized exercise" 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? "2. Establish a trusting relationship with the client. "Which task is most important when developing a plan of care for a client with anorexia nervosa? "4. Evaluating exercise activities 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? 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. 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? "Please go to bed now. We'll talk in the morning." 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? "4. Diaphoresis, tremors, and nervousness 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? "3. The client keeps a journal and discusses it with the nurse. 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. Arranging for a presentation by a local teenager who was involved in an alcohol-related traffic fatality 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? "4. ""I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."" The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: 3. identify anxiety-causing situations. 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? "1. Al-Anon 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. jointly by the client and nurse. A client begins to experience alcoholic hallucinosis. What is the appropriate nursing intervention at this time? "3. Providing a quiet environment and administering medication as needed and prescribed