Mental Health 2019 B Practice
1) 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?
-An adolescent family member who questions parental authority
An adolescent who questions pare...
mental health 2019 b practice 1 a nurse is assessing a family’s dynamics during a counseling session the nurse should recognize which of the following findings as an in
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Mental Health 2019 B Practice
1) 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?
-An adolescent family member who questions parental authority
An adolescent who questions parental authority is demonstrating appropriate behavior for developmental age.
-A family with three generations in the same household
This scenario occurs in many households, and it is not an indication of a boundary issue.
-Older children who are responsible for their younger siblings
This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.
-Two adults and their children from prior relationships in the same household
This is an example of a blended family, and it is not an indication of a boundary issue.
2) A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful.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.
According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.
-Introduce the client to other clients in the day room.
The nurse should introduce the client to other clients in the day room to help the client interact with others during the working phase of the nurse-client relationship. However,
evidence-based practice indicates that the nurse should take a different action first.
-Assist the client in facilitating behavioral change.
The nurse should assist the client with behavioral change during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse
should take a different action first.
-Determine coping strategies that the client has used in the past.
The nurse should determine what coping strategies the client used in the past during the working phase of the nurse-client relationship. However, evidence-based practice
indicates that the nurse should take a different action first.
3) 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?
-Slow onset
Delirium has an acute onset. Dementia is a slow, progressive decline.
-Aphasia
Aphasia is a manifestation of dementia.
-Confabulation
Confabulation is a manifestation of dementia.
-Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
4) A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client’s plan of care?
-Offer the client various choices for meal selection.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by limiting the choices the client is asked to make.
-Assign different nursing personnel for each shift.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing consistent nursing personnel.
-Permit the client to perform daily rituals to decrease anxiety.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.
-Maintain an environment that has low lighting.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing a well-lit environment.
5) A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in
the plan of care?
-Encourage the client to participate in group therapy.
The nurse should maintain a low-stimuli environment for a client who is experiencing mania. The nurse should dim the lights, decrease noise, and limit the number of people
the client is around.
-Instruct the client to avoid napping during the day.
The nurse should encourage the client to take frequent rest periods throughout the day. Clients experiencing mania are at risk of exhaustion that can be life threatening.
-Offer the client high-calorie finger foods frequently.
The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals
and can experience weight loss and dehydration.
, -Decrease the client's daily fiber intake.
The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients experiencing mania can experience dehydration and nutritional deficiencies from
decreased intake, which can lead to constipation.
6) 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?
-Obsessive attention to detail
During the manic phase of bipolar disorder, a client's behavior becomes disorganized and chaotic, which renders the client unable to focus on detail.
-Inability to sleep
During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.
-Reports of fatigue
Although the client who is experiencing acute mania might eventually become exhausted, there is a characteristic unawareness of fatigue during this phase.
-Isolation from others
Clients who are in the manic phase of bipolar disorder often talk and joke incessantly and are highly interactive.
7) A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
-Orient the client to person, place, and time.
A client who is experiencing a panic attack is generally not disoriented.
-Assist the client with deep-breathing exercises.
Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.
-Calm the client by using therapeutic touch.
Therapeutic touch is not intended to de-escalate panic in a client who is anxious.
-Have the client sit alone in a quiet room.
It is recommended that the nurse stay with a client who is experiencing panic anxiety to ensure the client's safety.
8) A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?
-Encourage the parents to avoid discussing the death with their other children to protect their feelings.
Siblings also experience feelings of intense grief and need to know it is acceptable for the family to grieve together.
-Recommend each parent grieve in private to avoid hindering each other's healing.
Although parents tend to grieve differently, it is important they share their grief and communicate their needs to decrease the likelihood of marital upset.
-Suggest forming a weekly support group for parents who have experienced the death of a child.
Support groups are a positive resource in the process of recovery for parents following the death of a child.
-Advise the parents to begin counseling if they are still grieving in a few months.
The grief process varies for each individual. Setting an expected period for grief places the parents at risk for further problems if they feel they have not completed the grieving
process in an acceptable amount of time.
9) A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?10)
-Complete documentation about the client's status every hour while they are in restraints.
The nurse should document the client's status, including behavior and vital signs, and address the client's physical and safety needs every 15 min.
-Maintain the client in restraints for a minimum of 4 hr.
Restraints should be removed as soon as the client is able to follow instructions, control their behavior, and is no longer at risk for injuring themselves or others. The maximum
amount of time an adult client should remain in restraints is 4 hr.
-Apply restraints when other means of managing the client's behavior have failed.
According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation
methods for controlling behavior should be attempted prior to initiating restraints.
-Request that the provider assess the client within 8 hr of the application of restraints.
The use of mechanical restraints requires a provider's prescription. In emergent cases, the prescription can be obtained after restraints have been applied. However, the
provider must evaluate the client within 1 hr of the initiation of restraints
10) A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
-Sedation
The nurse should expect the client experiencing opioid withdrawal to have insomnia.
-Rhinorrhea
The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.
-Bradycardia
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