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

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?

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?

Which statement best describes the practice of psychiatric nursing?

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?

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

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?

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?

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

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:

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.

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?

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?

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?

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?

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?

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?

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

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

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?

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?

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

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.

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

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

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.

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?

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

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

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?

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

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?

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?

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

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?

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

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

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

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?

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

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?

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

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

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

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?

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

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?

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

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?

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?

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?

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

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

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

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?

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

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?

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

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

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?

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

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.

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.

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.

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?