WITH DETAILED ANSWERS 2024 -2025 A+
GRADED
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 - ANSWERS -plan a list of activities to be carried
out daily... Bipolar patients who manifest behavior that interferes with ability to function
do better when given a schedule to adhere to with a list of planned daily activities
*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 - ANSWERS -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 - ANSWERS -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 - ANSWERS -"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 - ANSWERS -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 - ANSWERS -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 that
the client is coping well with the anxiety related to the student's death - ANSWERS -
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 information
supports the reason for this laboratory test - ANSWERS -Lithium is excreted by the
kidneys and creatinine is related to kidney functioning
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? - ANSWERS -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 should the
nurse take - ANSWERS -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 -
ANSWERS -"I am here because the police thought I was doing something wrong"
Projection- transferring one's internal feelings, thoughts, and unacceptable ideas and
traits to someone else (Saunders 991.)
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 aside, looking
for a red one to sit in. When another client objects to the disturbances, the client
shouts," I am the boss here. I do what I want." Which nursing problem best supports
these observations - ANSWERS -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. What is the
most likely source of this client's current feelings of depression - ANSWERS -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 - ANSWERS -[...]
Rational: The nurse also looks for indications that the patient is communicating thoughts
and feelings more readily and that the patient's social network is widening. If the person
is able to talk about feelings and engage in problem solving with you, this is a positive
sign (Varcarolis 485.)
What nursing assessment is the priority focus for a client with major depression? -
ANSWERS -suicidal ideation: suicidal ideation is a major risk factor in a client with
major depression
, 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 nurse
take first - ANSWERS -observe the client in the chair
A homeless person who is in the manic phase of bipolar disorder is admitted to the
mental health unit.. Which lab finding obtained on admission is most important for the
nurse to report to the HCP? - ANSWERS -decreased thyroid stimulating hormone level
Rational: hyperthyroidism causes an increased level of serum thyroid hormones (T3 and
T4), which inhibit the release of TSH, so the clients manic behavior may be related to an
endocrine disorder.. elevated liver function profile, increased WBC count, and
decreased hematocrit and hemoglobin levels are abnormal findings that are commonly
found in the homeless population because of poor sanitation, poor nutrition, and the
prevalence of substance abuse
*The nurse is teaching a client about the initiation of a prescribed abstinence therapy
using disulfiram (Antabuse). What information should the client acknowledge
understanding - ANSWERS -remain alcohol free for 12 hours prior to the first dose
How do you take antabuse - ANSWERS -must have patient consent
When preparing to administer a domestic violence screening tool to a female client,
which statement should the nurse provide - ANSWERS -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 - ANSWERS -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 - ANSWERS -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 - ANSWERS -delay business
decisions until his mania subsides
one on one session and nurse begins to get angry at patient - ANSWERS -terminate
session
*patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contant
healthcare provider before giving - ANSWERS -acetaminophen