Download Mental Health Nursing Exam Questions and Answers and more Exams Nursing in PDF only on Docsity!
MENTAL HEALTH RN CLINICAL
ASSIGNMENT 2025 – COMPLETE
A+ GRADED NURSING
DOCUMENTATION WITH PATIENT
CASE STUDY, THERAPEUTIC
COMMUNICATION TECHNIQUES,
MENTAL STATUS EXAMINATION,
NURSING DIAGNOSES, AND
EVIDENCE-BASED CARE PLAN
The nurse is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention? A) Very high temperature B) Muscular rigidity C) Tremors
D) Altered consciousness - -- <<<> >> ---A) Very high temperature A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Ability) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply. A) Headaches that will subside in a few weeks B) Transient mild anxiety C) Insomnia D) Torticollis E) Pill rolling movements - -- <<<> >> ---A) Headaches that will subside in a few weeks B) Transient mild anxiety C) Insomnia An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and instance, the daughter calls the nurse to report her mother's behavior. Which of the following would the nurse suspect as
D) Grape juice - -- <<<> >> ---C) Cranberry juice A client diagnosed with paranoid schizophrenia is still withdrawn, unkept, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The nurse should tell the health aide: A) "Prolixin is the most effective with positive symptoms of schizophrenia." B) "The client will be less withdrawn and unmotivated when the Prolixin takes effect." C) "The client's Prolix dose probably needs to be increased again." D) "Lack of motivation is a common side effect of the Prolixin." - -- <<<> >> ---A) "Prolixin is the most effective with positive symptoms of schizophrenia." if a female client is sitting alone in the group room of psychiatric unit, nodding head and talking to herself, hearing voices and they are telling her to turn herself in to FBI, what should the PN do? - -- **_<<<<ANSWER
** ---Distract her by turning on tv An OCD patient repeatedly washing a table top. What intervention should the PN do? - -- **<<<> >>_** ---Allow time for behavior and then redirect to other activities
A highly successful businessman presents to community mental health after complaining of sleepiness and anxiety over his financial status. What should the PN do to diminish his anxiety? - -- <<<> >> - --Teach him to limit sugar and caffeine intake. A patient is being discharged from psychiatric facility with a prescription for the anti psychotic agent (Mellaril). What should the PN tell the patient to do? - -- <<<> >> ---Stand up slowly because the medication can cause hypotension. An 18 year old has been told he has Hodkins disease when the PN enters the room. He yells to get out, I want to die. What should the PN tell him? - -- <<<> >> ---Tell me what the health care provider said. The grandmother of a young adult male admitted to psychiatric unit request info about his treatment. What should the PN do? - -- <<<> >> ---Ensure a signed release of info includes grandma. A client experiencing withdrawal from Xanax is having severe agitation and tremors. What should the PN do? - -- <<<> >> ---Initiate seizure precaution. A daughter gained weight because she is under so much stress deciding whether to send dad to nursing home or her home. What should the PN
<<<> >> ---TELL ME WHAT YOU THINK WILL HAPPEN TO YOU
IF YOU DO CONTINUE TO DRINK
A 4 YEAR OLD IS BROUGHT TO THE CLINIC WITH A FRACTURED
ARM.WHICH INFORMATION SHOULD BE A BASIS FOR THE PRACTICAL
NURSE TO SUSPECT CHILD ABUSE - -- <<<> >> ---THE CHILD
HAS HAD 4 PREVIOUS VISITS TO 3 NUMBER OF EMERGENCY
DEPARTMENT
NURSING MEASURE FOR VICODIN - -- <<<> >> ---OBSERVE
THE CLIENT FOR FURTHER NARCOTIC EFFECTS
OLDER CLIENT BECOME DISORIENTED AND CONFUSED. SIGNS OF LEFT
EXTREMITY WEAKNESS BUT NO NEURO CHANGES. - -- <<<>
>> ---CALL AN AMBULANCE TO TAKE THE CLIENT TO THE HOSPITAL
HALDOL INCREASE TEMP: 104 F AND MUSCULAR RIGIDITY - --
<<<> >> ---CALL AN AMBULANCE
ALZHEIMER'S PATIENT ADMITTED TO AN EXTENDED CARE FACILITY.
WHAT SHOULD YOU DO? - -- <<<> >> ---PLAN TO HAVE THE
SAME NURSING STAFF PROVIDE CARE FOR THE CLIENT WHENEVER
POSSIBLE
A FEMALE CLIENT COULD NOT SLEEP LAST NIGHT BECAUSE SHE IS
UNHAPPY IN HER JOB.WHAT TYPE OF THOUGHTS IS THE CLIENT HAVING
- -- <<<> >> ---OBSESSIVE THOUGHT THAT THE CLIENT IS
UNABLE TO CONTROL
Alcohol withdrawal-hospitalization - -- <<<> >> ---Alcohol detoxification precipitates a withdrawal syndrome that includes neurological and cardiovascular changes that require constant monitoring and medical management to safely move the client to an alcohol-free physiology. The other responses are ineffective and may contribute to the client's defensiveness. Depression-1st priority - -- <<<> >> ---Maslow's hierarchy or needs begins with ensuring physiologic needs and safety as primary needs. The priority investigation is to provide a safe stable, and predictable routine that will meet the client's basic needs. The other actions are indicated, but first an environment that is predictable should be ensured to facilitate the client's participation in self care. Abuse-spousal - -- <<<> >> ---The PN should ask a direct question that is supportive and nonjudgmental, and the best approach is the question, is someone hurting you? The other questions are probing and judgmental and are not the best approach to sensitive information.
Suicide-narcan - -- <<<> >> ---The half-life of hydrocone (Vicodin) is 3.8 hours, and the half-life of naloxone (Narcan) is 60 to 90 minutes. The effects of hydroconone will outlast the antagonist effects of naxolone, and further dosage with naloxone may be required. In planning care, it is most importantly that the client is observed closely for recurrence of narcotic actions until the effects of hydrocodone have been eliminated. Other actions are not the priority action at this time. Reflective dialog - -- <<<> >> ---The PN should first demonstrate therapeutic communication by being present and actively listening to the client. Sharing a perception of what is happening with the client is a useful communication technique that prvides the client an opportunity to verify the PN's perception and asses the client to clarify and focus on the decisional conflict that is being experienced. Examples of nontherapeutic techniques in communication include giving advice, giving reassurance and failing to explore the client's feelings. Antidepressants - -- <<<> >> ---Tolerance to anticholinergic side effects caused by tricyclic antidepressants (TRC) develops gradually and typically inscludes dry mouth, blurred vision, and constipation. The other findings are adverse reactions to TRC antidepressants, not expected side effects.
Anxiety-nursing action - -- <<<> >> ---The best intervention is to encourage verbalization and explore reasons for wanting to be discharged. The other actions should be implemented after determining the source of the client's anxiety. A CLIENT WITH DELUSIONS, "YOU ARE NOT DOING YOUR JOB. GO GET THOSE PEOPLE OVER THERE AND SHOUT THEM BEFORE THEY GET ME. WHAT IS THE NURSE BEST RESPONSE - -- <<<> >> ---YOU SEEM QUITE FRIGHTENED RIGHT NOW A SINGLE MOTHER (CHILD HAVING HEAD INJURY) WHY DID THIS HAPPEN TO MY CHILD. I CAN'T JUST COPE WITH THIS - -- **_<<<<ANSWER
** ---EXPRESS CONCERN ABOUT THE IMPACT OF THE EVENT ON THE MOTHER. A DELUSIONAL CLIENT WITH AGITATION AND LOSING CONTROL WHAT ARE SOME NURSING INTERVENTIONS? - -- **<<<> >>** ---MOVE THE CLIENT TO A QUIET PLACE ON THE UNIT. ANOREXIA NERVOSA DESIRED OUTCOME: - -- **<<<> >>** --- CONSUME AT LEAST 50% OF ALL MEALS A PARANOID CLIENT SITS QUIETLY WITHOUT COMMUNICATING THE NURSE SHOULD? - -- **<<<> >>** ---EXPLAIN HIS ROLE TO THE ** ---Tolerance to anticholinergic side effects caused by tricyclic antidepressants (TRC) develops gradually and typically inscludes dry mouth, blurred vision, and constipation. The other findings are adverse reactions to TRC antidepressants, not expected side effects. Anxiety-nursing action - -- **<<<> >>** ---The best intervention is to encourage verbalization and explore reasons for wanting to be discharged. The other actions should be implemented after determining the source of the client's anxiety. A CLIENT WITH DELUSIONS, "YOU ARE NOT DOING YOUR JOB. GO GET THOSE PEOPLE OVER THERE AND SHOUT THEM BEFORE THEY GET ME. WHAT IS THE NURSE BEST RESPONSE - -- <<<> >> ---YOU SEEM QUITE FRIGHTENED RIGHT NOW A SINGLE MOTHER (CHILD HAVING HEAD INJURY) WHY DID THIS HAPPEN TO MY CHILD. I CAN'T JUST COPE WITH THIS - -- <<<> >> ---EXPRESS CONCERN ABOUT THE IMPACT OF THE EVENT ON THE MOTHER. A DELUSIONAL CLIENT WITH AGITATION AND LOSING CONTROL WHAT ARE SOME NURSING INTERVENTIONS? - -- <<<> >> ---MOVE THE CLIENT TO A QUIET PLACE ON THE UNIT. ANOREXIA NERVOSA DESIRED OUTCOME: - -- <<<> >> --- CONSUME AT LEAST 50% OF ALL MEALS A PARANOID CLIENT SITS QUIETLY WITHOUT COMMUNICATING THE NURSE SHOULD? - -- <<<> >> ---EXPLAIN HIS ROLE TO THE CLIENT BEFORE CARING FOR THIS CLIENT
down, or under the weather. The PN should ask, "Do you often feel sad?" the other factors may occur with depression, but the other questions do not focus on the assessment of the client's mood, which is best in determining the existence of depression. Abuse-spousal - -- <<<> >> ---The PN should ask a direct question that is supportive and nonjudgemental, and the best approach is the question, is someone hurting you? The other questions are probing and judgemental and are not the best approach to sensitive information Child abuse-historic signs - -- <<<> >> ---Trauma in a child, such as an arm fracture should be assessed for other common trends in parenting that may be the result of child abuse, which can be life- threatening and require reporting to the proper authorities. Repeating visits to one or more emergency departments with injuries to the child is a sign of possible physical abuse. The other finding describe normal behavior for an injured child and family dynamics that are not necessarily a sign of potential child abuse. Benzodiazepine-instruct - -- <<<> >> ---Aalprazolem (Xanax) is contraindicated in acute angle-closure glacoma or untreated open- angel glaucoma. The PN should instruct the family and client to call the clinic if the client is diagnosed with acute narrow angle glaucoma. The other options are important interventions but they do not have priority
Suicide-narcan - -- <<<> >> ---The half-life of hydrocodone (Vicodin) is 3.8 hours, and the half-life of nalaxone (Narco) is 60-90mins. The effects of hydrocodone will outlast the antagonist effects of naloxone, and further dosage with naloxone may be required. In planning care, it is most important that the client is observed carefully for recurrence of narcotic actions until the effects of hydrocodone have been eliminated. The other actions are not the priority action at this time. Anxiety-nursing action - -- <<<> >> ---The best intervention is to encourage verbalization and explore reasons for wanting to be discharged. The other actions should be implemented after determining the source of the client's anxiety. Antidepressant - -- <<<> >> ---Tolerance to anticholinergic side effects caused by tricyclic antidepresaents (TBC) develops gradually and typically include dry mouth, blurred vision, and constipation. The other findings are adverse reactions to TBC antidepressants, not expected side effects. Reflective dialog - -- <<<> >> ---The PN should first demonstrate therapeutic communication by being present and actively listening to the client. Sharing a perception of what is happening with the client is useful communication technique that provides the client an opportunity to verify the PN's perception and assists the client to clarify and focus on the decisional conflict that is being experienced. Examples
monitoring and medical management to safely move the client to an alcohol-free physiology. The other responses are ineffective and may contribute to the client's defensiveness. Neuroleptic malignant syndrome - -- <<<> >> ---The client is exhibiting symptoms of the life-threatening condition, neuroleptic malignant syndrome, which is associated with the typical antipsychotic, Maldol. The emergency response team should be notified immediately and the client transferred to the intensive care unit as soon as possible. The other actions do not address the critical symptoms the client is exhibiting. Medication compliance - -- <<<> >> ---Noncompliance with the medication regimen is a significant problem that needs to be addressed for a client in the manic phase of bipolar disorder. The client should be escorted to her room where she is less stimulated and more likely to be receptive to compliance. The other actions continues to provide stimulation and are not the best method at this time to facilitate compliance Duty to warn - -- <<<> >> ---The duty to protect, or Tarasoff Principle, is based on the legal case that supports a potential victim's right to be informed of physical threats, which provides reasonable care to protect the intended victim. The other actions are important but are of a lower priority.
Wandering-safety - -- <<<> >> ---The client may waner into unsafe places or situations. Constant observation is necessary when a client has poor judgment and wanders into other clients' rooms. The other findings are not a risk to client safety. Crying mother approach - -- <<<> >> ---An open-ended communication approach that acknowleges the client's feelings employs empathy, caring, and compassion. The PN should express concern about the impact of the event and encourage further verbalization by the mother. The other approaches do not help the mother gain insight into her feelings. Suicide-elderly evaluation - -- <<<> >> ---Based on this client's age and gender, he is at risk for suicide related to his loss and grief. The PN should open the conversation about his wife to allow his reminiscing and to determine the degree of "sadness" he is feeling. The other options are probing of no consequence, dismiss his feelings, and are a platitude and not helpful. benzodiazepine (xanax) is given to a client and he suddenly has agitation and tremors. what are some nursing measures - -- <<<> >> ---initiate seizure precautions
- At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders
should I stand for the parade?" Which response is best for the nurse to provide? A "Anywhere you want to stand as long as you do not get hurt by those in the parade." B "You are confused because of all the activity in the hall. There is no parade." C "Let's go back to the activity room and see what is going on in there." D "Remember I told you that this is a nursing home and I am your nurse." - -- <<<> >> ---C. Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate? A "I need to inform the healthcare provider about your child's tendency to be accident prone." B "Tell me more specifically about your child's accidents." C "I must report these injuries to the authorities because they do not seem accidental." D "Boys this age always seem to require more supervision and can be quite accident prone." - -- <<<> >> ---B
A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is A regressing to an earlier behavior pattern. B sublimating her anger. C projecting her feelings onto the nurse. D suppressing her fear. - -- <<<> >> ---C . A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make? A "I'll leave your tray here. I am available if you need anything else." B "You're not being poisoned. Why do you think someone is trying to poison you?" C "No one on this unit has ever died from poisoning. You're safe here." D "I will talk to your healthcare provider about the possibility of changing your diet." - -- <<<> >> ---A.
