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Mental Health Nursing Exam 2019
Psychiatric Nursing (Northern Virginia
Community College)
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Systematic Desensitization : The client is able to drive down a familiar street without experiencing a panic attack, indicating positive results from the behavioral therapy program. To continue the positive results, the nurse should recommend that the client participate in positive reinforcement.
Positive reinforcement helps to strengthen the desired behavior (driving without panic) and encourages the client to continue the therapy.
Maladaptive Grieving :
Maladaptive grieving is a distorted or exaggerated grief response that prevents the individual from performing daily activities. Risk factors for maladaptive grieving include: Being dependent upon the deceased Unexpected death at a young age, through violence, or by a socially unacceptable manner Inadequate coping skills or lack of social support Pre-existing mental health issues, such as depression or substance use disorder
The statement that indicates maladaptive grieving is: "I still don't feel up to returning to work." (8 months is too long for the client to be unable to perform daily activities).
Complications of Haloperidol (Antipsychotic, First-Generation) :
The nurse's priority is to assess for urinary hesitancy , which is a complication due to the anticholinergic effects of the medication.
Other complications include:
Acute dystonia Pseudoparkinsonism Akathisia Tardive dyskinesia
Neuroendocrine effects (Gynecomastia, Weight gain, Menstrual irregularities) Neuroleptic Malignant Syndrome (NMS) Orthostatic Hypotension Sedation Sexual dysfunction Skin effects Liver impairment
Recommendations for Obsessive-Compulsive Disorder (OCD) :
The nurse should include Thought Stopping in the client's plan of care. Thought Stopping involves teaching the client to say "stop" when compulsive behaviors arise and substitute them with positive thoughts.
The statement by the daughter that indicates an understanding of the teaching is: "I will limit my mother's clothing choices when she is getting dressed." This helps to limit the client's choices and reduce indecisiveness.
Caring for a Client in the Manic Phase of Bipolar Disorder :
The nurse should avoid power struggles by remaining neutral and not react personally to the client's comments. The nurse should decrease stimulation by encouraging the client to participate in group activities.
The nurse should set limits for the client's behavior, as the client may be unable to set their own limits during the manic phase.
Thought Stopping Technique for OCD :
The nurse should instruct the client to focus on abdominal breathing whenever they go to check the locks.
Thought Stopping involves teaching the client to say "stop" when negative thoughts or compulsive behaviors arise and substitute them with positive thoughts. The goal is for the client to use the command silently over time.
Cocaine Withdrawal Manifestations :
During cocaine withdrawal, the nurse can expect the client to experience depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, and psychomotor retardation.
Cocaine is a stimulant, so the withdrawal symptoms are the opposite of the effects during intoxication.
Monitoring Clozapine :
Outcomes for Autism Spectrum Disorder :
The nurse should include the outcome that the client initiates social interactions with the caregiver in the plan of care. Individuals with autism spectrum disorder have difficulties with communication and social interaction.
Caring for a Client with Active Auditory Hallucinations :
The nurse should attempt to focus the conversation on reality- based subjects and avoid asking direct questions about the client's experience. The nurse should convey sympathy for the client's experience but avoid telling the client that the hallucination is not real.
Reporting Findings during a Manic Episode :
The nurse should report to the provider that the client reports eating twice in the past week , as this could indicate physical exhaustion and a potential medical emergency.
Immediate Intervention for Anorexia Nervosa :
The nurse should immediately intervene for the finding of + edema of the lower extremities , which indicates hypokalemia due to purging or vomiting, leading to dehydration and electrolyte imbalance.
Outcomes for Antisocial Personality Disorder :
The nurse should include the outcome that the client conforms to social norms regarding clothing choices in the care plan. Individuals with antisocial personality disorder often have a disregard for social norms and a sense of entitlement.
Responding to a Client's Aversion to Touch :
The nurse should avoid the client's triggers and respond by saying, "I will tell your provider that you would like a treatment other than a massage."
Techniques for a Developmentally Disabled Client Stealing Belongings :
The nurse should use positive reinforcement to increase the desired behavior of not stealing, rather than aversion therapy or systematic desensitization.
Recommended Resources for a Newly Admitted Client :
The nurse should recommend a Community meeting to help the client adapt to the healthcare setting. Community meetings provide a structured forum for clients to discuss their concerns and adjust to the facility.
Home Safety Teaching for Alzheimer's Disease :
The caregiver's statement that indicates an understanding of the teaching is: "I will notify law enforcement within 2 hours if he cannot be found." This demonstrates the caregiver's awareness of the need to promptly report a missing client with Alzheimer's disease.
Tasks during the Working Phase of a Therapeutic Relationship :
The nurse should plan to establish trust and rapport, gather information, and develop a mutually agreed-upon plan of care during the working phase of the therapeutic relationship.
Establishing Boundaries and Goals in Nurse-
Client Relationships
Establishing Boundaries
Inform the client about their confidentiality rights Set clear boundaries between the nurse and the client
Evaluating Progress
Evaluate the client's progress toward predetermined goals
Setting Objectives
Set short-term and long-term objectives for the client's future
Nursing Care for Clients with Anorexia
Nervosa
Systematic Desensitization
Use systematic desensitization to address the client's fears regarding weight gain
Meal Times
Allow the client to select meal times A structured and inflexible eating schedule at the start of therapy, only permitting food during scheduled times, promotes new eating habits and discourages binge or binge-purge behavior
Building Trust
Initiate a relationship built on trust with the client
Transcranial Magnetic Stimulation (TMS)
Teaching
Potential Side Effects
The client might have a headache after treatment (a/e mild discomfort and tingling sensation at the site of the electromagnet)
Client Safety
The client is alert during the procedure (the client will not require intubation) The client is not at risk for aspiration during treatment (nothing is placed in the mouth, only a noninvasive magnet in the head) The client is not at risk for seizure during treatment (RARE, more common with ECT)
Speech Alterations in Clients
Clang Association
Meaningless rhyming of words, often forceful, such as, "Oh fox, box, and lox."
Echolalia
Repeating words spoken to the client
Word Salad
Words jumbled together with little meaning or significance to the listener, such as, "Hip hooray, the flip is cast and wide-sprinting in the forest."
Neologism
Made-up words that have meaning only to the client, such as, "I tranged and flittled."
Neuroleptic Malignant Syndrome (NMS)
Clinical Findings
Muscle rigidity Sudden high fever (temperature 40°C or 104°F) Bradycardia (heart rate 48/min) Leukopenia (WBC 3,000/mm³)
Other findings: blood pressure fluctuations, diaphoresis, tachycardia, drooling, decreased level of consciousness, coma, and tachypnea
Discharge Planning for Clients with
Traumatic Brain Injury
Collaboration with Clinical Psychologist
The client needs to begin a group therapy program prior to discharge The client needs to relearn how to perform skills that require fine motor coordination
Defense Mechanisms
Displacement
Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation
Medication Teaching for Clients with
Schizophrenia
Risperidone
Do not discontinue this medication if you develop muscle rigidity You may experience weight gain while taking this medication You may not notice symptoms improve within 24 hours of taking this medication Increase your consumption of complex carbohydrates (risk of Metabolic Syndrome)
Response to Inappropriate Comments in
Group Therapy
Nurse's Response
You sound upset about today's session I agree that the comment was inappropriate Why do you think that he said that to you?
Sit on the side of the bed for a few minutes before standing (orthostatic hypotension) Eat a snack before going to bed (sedation) Avoid over-the-counter magnesium when taking this medication (no interactions)
Borderline Personality Disorder and Self-
Mutilation
Recommended Group Therapy
Dialectical Behavior Treatment Group
Defense Mechanism: Amnesia
Client's Statement
"I don't remember what happened to me."
The client is using the defense mechanism of denial.
Medication Calculation: Haloperidol
The nurse should administer 1.4 mL of haloperidol injection 5mg/mL to provide the client with 7 mg of haloperidol IM.
Countertransference
Identifying Countertransference
The statement "The client is just like my brother who finally overcome his habit" demonstrates countertransference, as the nurse is displacing characteristics of people in her past onto the client.
Medication Teaching: Phenelzine
Avoiding Tyramine-Rich Foods
The nurse should instruct the client to avoid foods with tyramine to prevent a hypertensive crisis.
Tyramine-rich foods include aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein, some dietary supplements, some beers, and red wine.
Transference and Personality Disorders
Transference in Personality Disorders
Transference occurs when a client views a member of the healthcare team as having characteristics of another person who has been significant in the client's personal life. In the case of a client with a personality disorder, the nurse can expect the following behaviors:
Reaction to the nurse as though she were the client's mother (b) Expressing frustration regarding unit rules (c) Talking negatively about other staff members (d)
The client may not be willing to participate in group activities (a) due to the transference reactions.
Nursing Care for Clients with Generalized Anxiety Disorder
When admitting a client with generalized anxiety disorder, the nurse should first determine how the client handles stress (a). This assessment provides important information to guide the nursing interventions.
Providing a quiet environment (c) and teaching the client to use guided imagery (d) can also be beneficial, but these should be implemented after the initial assessment.
Medication Management for Clients with
Bipolar Disorder
Lithium Carbonate Education
When teaching a client with bipolar disorder about a new prescription for lithium carbonate, the following statement indicates the client's understanding:
"I will see my doctor to check my lithium level annually" (c)
The client should be on a normal sodium diet (a), and the recommended water intake is 1.5-3 liters per day (b). Diarrhea is an early indication of lithium toxicity, so the client should call the doctor if they experience this (d).
Nursing Interventions for Panic Attacks
When caring for a client experiencing a panic attack, the nurse should:
Provide a calm and quiet environment to decrease stimuli (c) Avoid seclusion, as this may increase the client's anxiety (a) Speak to the client in a calm, low-pitched voice (b)
Nursing Strategies for Borderline Personality
Disorder
The priority nursing strategy for a client with borderline personality disorder is to implement measures to prevent intentional self-inflicted injury (c). Other strategies, such as discussing assertive behavior (a), maintaining awareness of thoughts and feelings (b), and encouraging support group attendance (d), are also important but secondary to the client's safety.
Medication History for Smoking Cessation
When obtaining a medical history from a client requesting a prescription for bupropion for smoking cessation, the nurse should report a recent head injury (c) to the provider. Bupropion can increase the risk of seizures in clients with a history of head injury.
Knee arthroplasty (a), hepatitis B infection (b), and hypothyroidism (d) are not contraindications for bupropion use.
Nursing Care for Manic Episodes in Bipolar
Disorder
When caring for a client experiencing a manic episode of bipolar disorder, the nurse should:
Dim the lights in the client's room (c) to help promote a calm environment Avoid administering methylphenidate (a), as this would further stimulate the client Encourage the client to join group activities (b) to help channel their energy Provide detailed explanations to the client (d) may not be the most effective approach during a manic episode
Nursing Interventions for Suicide Attempt
When caring for a client admitted after a suicide attempt, the nurse's first priority is to implement continuous one-to-one observation (a) to ensure the client's safety.
Establishing rapport to foster trust (b), asking the client to sign a no-suicide contract (c), and encouraging group therapy (d) are also important, but the immediate focus should be on constant monitoring.
Hospitalization Criteria for Anorexia Nervosa
Indicators that a client with anorexia nervosa requires hospitalization include:
Heart rate less than 40 beats per minute (b) Weight loss greater than 30% of body weight over 6 months (d)
Potassium level of 3.8 mEq/L (c) is within the normal range.
Constructive Use of Defense Mechanisms
When teaching a newly licensed nurse about the constructive use of defense mechanisms, the nurse should include the following example:
A school-age child whose mother died 2 years ago talks about her in the present tense (a)
This demonstrates the defense mechanism of denial, which can be a constructive coping strategy in the short term.
Medication Interactions with Phenelzine
When caring for a client with a prescription for the monoamine oxidase inhibitor (MAOI) phenelzine, the nurse should instruct the client to avoid over-the-counter pseudoephedrine (d), as it can increase the risk of hypertension.
Docusate sodium (a) and ranitidine (c) are not contraindicated with phenelzine.
Assessing for Depression in Older Adults
When an older adult client is brought to the mental health clinic by a concerned daughter, the nurse should respond by asking the daughter to explain the reasons she thinks her mother is depressed (a). This allows the nurse to gather more information to assess the situation.
Dismissing the daughter's concerns (b, c, d) would not be an appropriate nursing response.
Nursing Interventions for Anorexia Nervosa
When planning care for a client with anorexia nervosa, the nurse should include the following interventions:
Weigh the client weekly for the first month (b) Notify the client about designated times for meals (c)
reactions, such as Stevens-Johnson syndrome, are a potentially life- threatening adverse effect of lamotrigine.
Thyroid function (a), nosebleeds (b), and liver enzyme levels (c) are also important to monitor, but a skin rash requires the most immediate attention.
Risk Factors for Schizophrenia
When assessing a young adult female client for schizophrenia, the nurse should identify environmental stress (b) as a risk factor for the condition. Other risk factors include gender (c), with schizophrenia being more common in males, and family history.
Birth order (a) and depression (d) are not considered risk factors for schizophrenia.
Therapeutic Communication for Delusional
Beliefs
When a client in a mental health facility expresses the delusional belief that the government is reading their mail, the nurse should respond in a therapeutic manner by acknowledging the client's fear and distress, rather than directly contradicting the delusion (c).
Statements that invalidate the client's experience (d) or attempt to rationalize the delusion (a, b) would not be appropriate nursing responses.
Identifying Delirium
When assessing a client who is restless and constantly muttering to themselves, the nurse should suspect delirium if the manifestation developed suddenly (c). Sudden onset of symptoms is a key characteristic of delirium, in contrast to the slow, repetitive speech (a) and flat affect (d) seen in other mental health conditions.
Inability to recognize objects (b) is not a specific indicator of delirium.
Crisis Intervention for Adolescents After
Suicide
When leading a crisis intervention group for adolescents who witnessed a classmate's suicide, the nurse's first action should be to identify the adolescents' prior coping skills (d). This provides a foundation for the nurse to build upon in helping the group members process the traumatic event.
Initiating referrals (a), discussing confidentiality (b), and reviewing community resources (c) are also important, but should follow the initial assessment of coping mechanisms.
Crisis Intervention for Violent Incidents
When providing crisis intervention for a client involved in a violent mass casualty situation, the nurse's initial actions should focus on reducing the client's stress-related manifestations, such as using techniques to alleviate a panic attack (b).
Identifying the client's usual coping style (a) and helping the client focus on a wide variety of crisis-related topics (d) may be beneficial, but should not be the nurse's first priority. Providing false assurance that the client's life will soon return to normal (c) would not be an appropriate nursing intervention.
Outcomes for Borderline Personality Disorder
When planning care for a client with borderline personality disorder, the nurse should include the outcome of the client communicating their needs (d) in the treatment plan.
Outcomes related to personal hygiene (a), mood improvement (b), and decreased hallucinations (c) may also be relevant, but are not the primary focus for a client with borderline personality disorder.
Informed Consent for Legally Incompetent
Clients
When assisting with obtaining informed consent for a client who has been legally declared incompetent, the nurse should contact the facility's social worker to obtain the necessary consent (b). The nurse should not attempt to explain implied consent to the client's family (a), as the client has been deemed legally incompetent.
