The Practice of Mental Health/Psychiatric Nursing

67問 • 1年前

問題一覧

Among members of the nursing team, which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply

Health promotion, Case management

A health care provider orders “Restraints prn” for a client who has a history of violent behavior. What is the nurse’s responsibility concerning this order?

Recognize that prn orders for restraints are unacceptable.

A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse’s response?

A client is allowed to consent or refuse potential psychi- atric treatments if a future incapacitating mental health crisis occurs.

Which statement best describes the practice of psychiatric nursing?

Helps people with present or potential mental health problems

A physician is admitted to the psychiatric unit of a community hospital. The client, who was restless, loud, aggressive, and resistive during the admission procedure, states, “Iwill take my own blood pressure.” What is the nurse’s most therapeutic response?

“I am sorry, but I cannot allow that because I must take your blood pressure.”

What is the most difficult initial task when developing a nurse-client relationship?

Developing an awareness of self and the professional role in the relationship

A parent of a 13-year-old adolescent who was recently diag- nosed with Hodgkin disease tells a nurse, “I don’t want my child to know the diagnosis.” How should the nurse respond?

“Let’s talk about your feeling regarding your child’s diagnosis.”

A male nurse is caring for a client. The client states, “You know, I’ve never had a male nurse before.” What is the nurse’s best reply?

“How do you feel about having a male nurse?”

A nurse reminds a client that it is time for group therapy. The client responds by yelling at the nurse, “You are always telling me what to do, just like my father!” What defense mechanism is the client using?

Transference

What is the most important tool a nurse brings to the therapeutic nurse-client relationship?

Oneself and a desire to help

A Latino client with schizophrenia is admitted to a mental health unit in an aggravated and disheveled state after failing to take prescribed medications for the last 5 days. When developing a plan of care that incorporates the client’s cul- tural background, the nurse gives priority to:

inclusion of the family in the plan of care with the client’s permission.

A family member brings a relative to the local community hospital because the relative “has been acting strange.” Which statements meet involuntary hospitalization criteria? Select all that apply.

“I would like to end it all with sleeping pills.”, “Voices say it is okay for me to kill all prostitutes.”

A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group?

Support

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because “I have nothing to talk about.” What is the best response by the nurse?

“You feel you will not be accepted unless you have some- thing to say?”

During a group meeting a client tells everyone, “I am afraid of my impending discharge from the hospital.” What is the most appropriate response by the nurse facilitator?

“Maybe others in the group have similar feelings that they would share.”

At a group therapy session a client tearfully tells the other members, “I just lost my job this week.” What is the nurse leader’s most appropriate response?

Quietly observe how the group responds to the client’s statement.

A 44-year-old client is unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis reflects this situation?

Situational

A client with the diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next?

Arrange a unit meeting to discuss what just happened.

A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting out behavior?

Teaching relaxation

A client is diagnosed with a borderline personality disorder. What is a realistic initial intervention for this client?

Establish clear boundaries.

A nurse is aware that a co-worker’s mother died 16 months ago. The co-worker cries every time someone says the word “mother” or if the mother’s name is mentioned. What does the nurse conclude about this behavior?

The co-worker may need help with grieving.

A nurse educator is leading a class on supporting middle-aged adults who are experiencing midlife crisis. What should the nurse include as the most significant factor in the development of this type of crisis?

The perception of their life situation

What is the priority goal when planning care for a client in crisis?

Restoring the client’s psychologic equilibrium

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a near panic state. The client states, “My partner just left me. I am a wreck.” What should the nurse do to help the client cope with this loss? Select all that apply.

Identify the client’s support systems., Encourage the client to talk about the situation.

Which approaches should a nurse use during crisis intervention? Select all that apply.

Active, Goal-directed

Which is the most important assessment data for a nurse to gather from the client in crisis?

The client’s perception of the circumstances surrounding the crisis

An extremely anxious client enters a crisis center and asks a nurse for help. Which response best reflects the nurse’s role in crisis intervention?

“I will be here for you to help you figure things out.”

When assisting clients to cope with a crisis, the health care provider should follow the principles of intervention. Place the following interventions in order of their priority. 1. ______ Stabilize the client. 2. ______ Intervene immediately. 3. ______ Encourage self-reliance. 4. ______ Use the available resources. 5. ______ Facilitate understanding of the event.

2,1,5,4,3

A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before assessing a child’s response to a crisis?

Developmental level of the child

What is an initial client objective in relation to anger management?

Taking responsibility for the hostile behavior

A nurse leads an assertiveness training program for a group of clients. Which client statement demonstrates that the treatment has been effective?

“It annoys me when people call me ‘Dearie,’ so I told him not to do it anymore.”

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, a nurse expresses disgust that the woman returns to the same situation. What is the nurse manager’s best response?

“Most woman attempt to leave about six times before they are able to do so.”

What is the most important information a nurse should teach to prevent relapse in a client with a psychiatric illness?

Follow the prescribed medication regimen

A depressed client has been prescribed a tricyclic antidepres- sant. How long should the nurse inform the client it will take before noticing a significant change in the depression?

2 to 4 weeks

A nurse is teaching clients about dietary restrictions when taking a monoamine oxidase inhibitor (MAOI). What response does the nurse tell them to anticipate if they do not follow these restrictions?

Occipital headaches

A client is receiving lithium. What is an important nursing intervention while this medication is being administered?

Monitor the client’s drug blood level regularly.

A client in the hyperactive phase of a mood disorder, bipolar type, is receiving lithium. A nurse identifies that the client’s lithium blood level is 1.8 mEq/L. What is the most appro- priate nursing action?

Hold the drug and notify the health care provider imme- diately because the blood lithium level may be toxic.

A nurse administers an antipsychotic to a client. For which common manageable side effect should the nurse assess the client?

Unintentional tremors

What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil

A nurse is caring for a client who abruptly withdrew from barbiturate use. What should the nurse anticipate that the client may experience?

Seizures

Chlordiazepoxide (Librium) 100 mg PO per hour is pre- scribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client had 300 mg in 3 hours and is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?

Administer chlordiazepoxide as indicated by the client’s CIWA score.

A client with schizophrenia who has type II (negative) symp- toms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symp- toms? Select all that apply

There is more interest shown in unit activities., The client performs activities of daily living independently.

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medica- tion, is unable to function, and must be rehospitalized. What medication may be prescribed that can be adminis- tered on an outpatient basis every 2 to 3 weeks?

Fluphenazine

A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the 6-week course of treatment?

Elimination of benzodiazepines for nighttime sedation

Imipramine (Tofranil), 75 mg three times per day, is pre- scribed for a client. What nursing action is appropriate when administering this medication?

Have the client checked for increased intraocular pressure and teach about symptoms of glaucoma.

A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication?

Staying in the sun

A nurse is evaluating the medication regimens of a group of clients to determine whether the therapeutic level has been achieved. For which medication should the nurse review the client’s serum blood level?

Valproic acid (Depakene)

A client with depression is to receive fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?

Blood levels may not be sufficient to cause noticeable improvement for 2 to 4 weeks

A client with type 1 diabetes is diagnosed with a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination?

Decreased control of the diabetes

In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), or benztropine (Cogentin) often prescribed?

Antipsychotics

A nurse is educating a client who is taking clozapine (Clozaril) for paranoid schizophrenia. What should the nurse emphasize about the side effects of clozapine?

Increase in temperature

A nurse is teaching clients in a medication education group about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?

ChlorproMAZINE

A primary nurse observes that a client has become jaundiced after 2 weeks of antipsychotic drug therapy. The primary nurse continues to administer the antipsychotic until the health care provider can be consulted. What does the nurse manager conclude concerning this situation?

Jaundice is sufficient reason to discontinue the antipsychotic.

A client has been receiving fluphenazine for several months. For which side effects should the nurse assess the client? Select all that apply.

Tremors, Uncoordinated movement of extremities

A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client?

Tardive dyskinesia

A monoamine oxidase inhibitor (MAOI) is prescribed. What should the nurse include in the teaching plan about what to avoid when taking this drug?

Ingesting aged cheeses

A client has been receiving escitalopram (Lexapro) for treatment of a major depressive episode. On the fifth day of therapy the client refuses the medication stating, “It doesn’t help, so what’s the use of taking it?” What is the nurse’s best response?

“Sometimes it takes 1 to 4 weeks to see an improvement.”

A client is receiving doxepin (Silenor). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client?

Mydriasis

A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the primary nurse, “Which of the prescribed medications will be most helpful for reducing psychotic signs and symp- toms?” What should the nurse respond?

Ziprasidone (Geodon)

A client with a psychosis is receiving olanzapine (Zydis). What is important for a nurse to consider when administering this drug?

It dissolves instantly after oral administration.

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply.

Rigidity, Tremors, Bradykinesia

A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, “Sometimes I forget to take the Cogentin.” What should the nurse teach the client to do if this happens again?

Take a dose as soon as possible, up to 2 hours before the next dose.

Olanzapine (Zyprexa) is prescribed for a client with bipolar disorder, manic episode. What cautionary advice should the nurse give the client?

Sit up slowly.

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? Select all that apply.

Diaphoresis, Hyperrigidity, Hyperthermia

Olanzapine (Zyprexa) is prescribed for a client who experienced agranulocytosis from Clozapine (Clozaril). Which statements indicate that the nurse’s teaching about olanzapine has been effective? Select all that apply.

“I need to be careful that I do not gain too much weight.”, “This medication should help me enjoy pleasurable activities.”

A client is admitted to the acute medical unit for severe amphetamine intoxication. Which medications should a nurse anticipate will be prescribed to counteract the effects of stimulant intoxication? Select all that apply.

Diazepam, Propranolol

A client with mild Alzheimer disease has been taking galantamine (Razadyne), and the health care provider prescribes paroxetine (Paxil) for depression. For what effect should a nurse assess the client when these medications are taken concurrently?

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Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS