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RN Mental Health Online Practice 202 5 B with
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A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? - ✔✔Easily distracted A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? - ✔✔"I'll stay with you just in case you want to talk." A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? - ✔✔A 35-year-old client who has major depressive disorder A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - ✔✔"I will update the plan of care as a client's manifestations of depression change." A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? - ✔✔Blood pressure 154/96 mm Hg A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the
client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? - ✔✔Nonmaleficence A nurse is discussing a 12 - step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? - ✔✔The client should obtain a sponsor before discharge for an increased chance of recovery. A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? - ✔✔Renew the prescription for the client every 4 hr. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? - ✔✔Inform the client that this admission is confidential. A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home? - ✔✔Assertive community treatment A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? - ✔✔Spending adequate time with a client who is verbally abusive. A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? - ✔✔"It is important for our child to have regular dental checkups."
A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? (Select all that apply.) - ✔✔Sodium Potassium BMI Bowel movement BUN Skin temperature Heart rate A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.) - ✔✔1.5 mL A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? - ✔✔A client who is experiencing delusions of persecution
A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? - ✔✔Language delay A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? - ✔✔Call for a team of staff members to help with the situation. A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? - ✔✔An older adult client who is bedbound and has a stage IV pressure ulcer A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicated an understanding of the teaching? - ✔✔"I will not take charge of my partner's work responsibilities." A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider? - ✔✔Inability to sleep A nurse is assessing a client who is displaying manifestations of delirium. Which of the following information from the client's medical record are risk factors for delirium? (Select all that apply.) - ✔✔Client's age Hospital environment
Insert indwelling urinary catheter: contraindicated IV fluids: anticipated MRI of the head: nonessential The nurse is planning care for the client who has delirium and new prescriptions. Complete the following sentence by using the lists of options. - ✔✔The nurse should first initiate IV fluids followed by administering acetaminophen. The nurse is caring for the client. Which of the following actions should the nurse take for this client? (Select all that apply.) - ✔✔Offer the client warm milk at bedtime Maintain a low-stimulation environment for the client Approach the client from the front and speak slowly The nurse is evaluating the client's response to treatments. For each assessment finding, click to specify if the finding is an improvement, no change, or a decline in the client's condition. - ✔✔Sleep/wake cycle: no change Vitals signs: improvement Daytime orientation: improvement
Glucose level: no change I&O: improvement Pain level: improvement Ambulation: decline in condition A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? - ✔✔"I will talk about my feelings with a close friend." A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? - ✔✔Tachycardia A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? - ✔✔Reduce environmental stimuli A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.) - ✔✔Occupational therapy Meal delivery services
"You should seek help if you have thought of self-harm." A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? - ✔✔"It appears as though you would like to open the door." A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take? - ✔✔Move the client who has bipolar disorder to a private room. A nurse is admitting a client who has major depressive disorder and a new prescriptions for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? - ✔✔Phenylephrine A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? - ✔✔Use a screening tool to evaluate the client for depression. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others? - ✔✔Command hallucinations A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? - ✔✔Older children who are responsible for their younger siblings
A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? - ✔✔"I am going to order a wheelchair for when I'm unable to walk." A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make? - ✔✔"Let's talk about what it upsetting you." A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? - ✔✔Stay with a client who has anorexia nervosa for 1 hr after mealtimes. A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? - ✔✔WBC count 2,500/mm^ A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? - ✔✔Identify signs of escalation of violence. Select the 6 findings found in the client's medical record that are manifestations of the client's diagnosed personality disorder. - ✔✔Physical altercations Incidences of self-injury Anxious if left alone
Hold next dose of buspirone: contraindicated Request change of diet to mechanical soft: nonessential Request prescription for digoxin 1 mg IV bolus STAT: contraindicated Calmly approach client and state," You seem agitated. Let's sit quietly and talk about it": anticipated The nurse is caring for the client. Which of the following actions should the nurse take? (Select all that apply.) - ✔✔Maintain continuous observation of the client while in restraints Conduct debriefing with the client and other staff The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not change, or has declined. - ✔✔Client follows instructions of the nurse: improved Client attempts to bite nursing staff when offered water: declined Client verbalizes precipitating factors to violent outburst: improved Client is silent and glaring at staff: no change
A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? - ✔✔Guided imagery
