Mental health 2 1.A Client is prescribed risperidone 4 mg PO BID. After the client is caught cheeking the medication a liquid medication is prescribed. Available is risperidone 0.5mg/ml . How many milliliters would be administered daily ? ( write the number only. Do not include the label. Round to the nearest whole number. Do not use a trailing zero.) 4/0.5=8mls ( that’s one dose) 8+8=16 16mls 2.An Adolescent tells the school nurse, “ My friend threatened to take an overdose pills.” The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask? a.Did something happen with your parents?
b.Have you been taking drugs and alcohol ?
c.Why do you want to kill yourself ?
d.Do you have access to medications? 3.A newly diagnosed client has a diagnosis of schizoaffective disorder. Based on this diagnosis, the nurse would expect to find which of the following symptoms a.Bizarre mannerisms and hostility b.Waxy flexibility and catatonic excitement c.Agitation and ideas of reference
d.Delusional thinking and mood changes
4.Which nursing documentation entry accurately describes the use of confabulation? a.Nonverbals indicate communication with unseen others
b.Attempts to communicate with by using rhyming words c.Rambles about early childhood experiences jumping from topic to topic d.Verbalizes happiness about trip to park which was not based on fact. 5.A client is admitted to the hospital for alcohol intoxication. The family reports that he is a heavy drinker and has been admitted several times for alcohol detoxification. When can the nurse expect to observe the first symptoms of withdrawl? a.Within 48 hours b.Within 8 hours c.Within 72 hours
d.Within 24 hours 6.The nurse has just finished up shift on an inpaitent psychiatric unit. Which of the following clients will the nurse assess first? a.A client with bipolar disorder who was prescribed lithium carbonate who woke this morning and having difficulty ambulating. b.A client with schizophrenia prescribed risperodone and paroxetine scheduled for discharge with a case management referral c.A client with schizophrenia who is refused morning medications stating “ you are trying to kill me with this drug” d.A client with bipolar disorder who is prescribed lithium carbonate and fluoxetine. The morning lab reports a lithium level of 0.6mmoI/L. e.A client withdrawing from opioid addiction reporting an escalation in anxiety to a moderate level and insomnia. 7.The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight what is the first action by the nurse?
a.Request help from other medical staff b.Check to see what medications the client is taking c.Encourage the client to eat more slowly d.Asses the client more thoroughly and immediately report any concerns to the provider.
8.A nurse is preparing to administer fluoxetine 80mg po daily. Available is 40mg/5mL. How many mL should the nurse administer per dose? 10 9.Benztropine is ordered as needed ( PRN ) for a client taking haloperidol after being diagnosed with schizoaffective disorder. Which of the following assessments by the nurse would indicate a need for this medication? a.The patient has complaints of dizziness. b.The client has elevated blood pressure. c.The client has extrpyrimdal symptoms ( EPS ) d.The client has increasing agitation
10.A client was diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to devolping a plan for safety. What should
be the nurses priority intervention at this time? a.Encouraging the client to verbalize feelings related to suicide
b.Conducting 15 minute checks to ensure safety
c.Placing the client on one- to one observation while monitoring for suicidal ideation d.Completing a room search to ensure there are no harmful objects available to the client.
11.The nurse is admitted a client with diagnosis of scizophreniform disorder. What should the nurse
expect to find? a.The client can accomplish all activities of daily living
b.The client is smiling and happy with their current lifestyle c.The client is euphoric with excessive energy d.The client has been experiencing hallications and delusions for less than 6 months
12.A client with schizophrenia reports auditory hallicinations, telling her that is a “terrible person”, “ a loser for having schizophrenia and “ she will never have a successful life”. The nurse understand which of the following is the priority concern?
a.Communication deficit related hallucination patterns
b.Risk for self harm related to poor self image c.Impaired social interactions related to negative self image d.Low self esteem related to negative thought process
e.Ineffective coping related to inability to manage hallucinations
13.A client states “ my life doesn’t have any happiness in it anymore. I once enjoyed going out with friends but now I don’t care if they even invite me. Which term best describes this clients feelings? a.Anergia b.Anhedonia c.Affect d.Agnosia 14.The client is prescribed phenelzine and is on a tyramine free diet what foods cannot be eaten ? SATA
a.A banana and iced coffee b.Chicken and mashed potatoes c.Plain ground beef patty with an apple d.A pepperoni and chesse pizza e.Smoked turkey and beans 15.A nurse is caring for a client diagnosed with premenstrual dysphoric disorder. What is the primary manifestation of this disorder ?
a.Anxiety b.Emotional lability c.Insomnia d.Loss of appetite
16.The nurse is teaching about obstacles to maintaining recovery. Which of the following would indicate to the nurse a greater risk for relapse? SATA
a.I don’t have a problem, I can quit when, where , and, how I want to b.I will start alcoholic anonymous meetings in two weeks when I am settled after discharge c.I am not going to let my family and friends know I have an addiction and give them this burden d.I don’t know how I am going to get through this but I am going to take it one day at a time with my family e.I know I am an addict, and it take hard work and a higher power to help me. 17.While caring for a depressed client , a nurse would evaluate the need for suicide precautions under which circumstance
a.The client displays agitation b.The client becomes suddenly cheerful c.The client experiences psychomotor retardation d.The client does not attend group therapy 18.A client receiving risperidone reports severe muscle stiffness at 10:30 , by 1200 the client has difficulty swallowing food and is drooling. The client is diaphoretic . By 1600 vital signs are as follows : temp 102.8 F , P 110 BPM , RR 26 breaths/minute and bp 150/90 mmHg. What is the nurses best analysis and action
a.Cholestatic jaundice: begin high protein , high cholesterol diet b.Neuroleptic malignant syndrome, notify healthcare provider stat c.Tardive dyskinesia: withhold the next dose of medication
d.Agranulocytosis institute reverse isolation precautions
19.The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway
and shouting at other clients. What is the priority action of the nurse ?
a.Coutine to observe the client for increased agitation b.Offer medications to help the client control his behavior
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