45) A nurse is creating a plan of care for a client who has… 45) A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?1) Encourage increased socialization during group therapy2) Avoid making eye contact when speaking with the client3) Provide reassurance and comfort for the client through touch4) Maintain a low level of environmental stimuli46) A nurse is providing teaching to a client who has major depressive disorder and a new prescription for citalopram. Which of the following statements should the nurse include in the teaching?1) You should check your urine for protein daily2) You should expect your depression to improve within 5 weeks3) You might experience constipation while taking this medication4) You might have an increase in anxiety during the first week of taking this medication47) A nurse is caring for a client who has bipolar disorder. The client is walking in and out of rooms, speaking inappropriately, and giggling. Which of the following actions should the nurse take?1) Lead the client outside for a walk2) Have the client return to her room to read a book3) Take the client to the day room to watch a movie with other clients4) Tell the client there will be negative consequences for her behavior48) A nurse is planning care for a client who demonstrates prolonged depression related to the loss of her partner 6 months ago. Which of the following actions should the nurse take?1) Explain that it can take a year or more to learn to live with a loss2) Suggest that the client avoid social interactions the remind her of her partner3) Discourage the client from reliving events surrounding her loss4) Direct the client to maintain an unstructured daily routine49) A nurse is assessing the boundaries of a clients family. One of the family members says to the client. “I know im exactly what you’re thinking right now.” The nurse should recognize that the family member is displaying which of the following types of family boundaries?1) Inconsistent2) Rigid3) Enmeshed4) Clear50) A nurse in an emergency department is caring for a client following a domestic dispute the client states.” Nothing seems to go right for me and probably never will.” Which of the following statements should the nurse make?1) We will help you get through this you will be fine2) Are you thinking about harming yourself3) What have you done to change your situation4) You should remove yourself from this situation now51) A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider? (Click on the Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.1) Edema2) Intake3) Heart rhythm4) TemperatureExhibit 2 Graphic ResultsBP 10064 mm HgPulse rate 58/minRespiratory Rate 16minTemperature 36.4*C (97.5*F)SaO2 96%BMI 1652) A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid food with tyramine to prevent which of the following?1) Cardiac toxicity2) Hypertensive crisis3) Urinary retention4) Serotonin syndrome53) A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?1) Encourage the client to avoid discussing the events surrounding the siblings death2) Caution the client against feeling angry at the sibling3) Explain to the client that the duration of grief is highly variable and can last for years4) Recommend that the client participate in more solitary activities54) After assessing a client in a crisis situation. A nurse determines the client is safe. Which of the following actions should the nurse take first?1) Teach the client specific coping skills to handle stressful situations2) Assist the client to lower his anxiety level3) Involve the client in planning interventions4) Help the client identify social support55) A nurse is teaching a client who has a new prescription for disulfiram. Which of the following statements by the client indicates an understanding of the teaching?1) If I cut myself, I can clean the wound with isopropyl alcohol2) I can wear my cologne on special occasions3) When I bake my favorite cookies. I can use pure vanilla extract for flavoring4) I can continue to eat aged cheeses and chocolate56) A nurse is caring for a client who has bipolar disorder and is experiencing maniac episode. Which of the following actions should the nurse take?1) Encourage the client to join group activities2) Provide detailed explanations to the client3) Administer methylphenidate to the client4) Dim the lights in the clients room57) A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanisms. Which of the following examples should the nurse use in the teaching?1) A school-aged child whose mother died 2 years ago talks about her in present tense2) An adult who was sexually abused as a child is unable to remember the incident3) A student who is upset with her teacher writes a story about an excellent student4) A woman who has a health concern postpones a medical appointment until after a vacation58) A nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse’s neighbor. The nurse should identify that which of the following must occur when establishing a therapeutic nurse-client relationship?1) The nurse maintains confidentially unless the clients safety is compromised2) The client regards the nurse as a friend3) The clients sees he north as an authority figure4) The nurse seeks to spend extra time specifically with the client on each day59) A nurse is providing teaching about lorazepam to a client who has an anxiety disorder. Which of the following statements should the nurse include in the teaching?1) You can take an extra dose of the medication if you are feeling very anxious2) This medication might cause a decrease in your blood pressure3) This medication might cause you to hyperventilate4) Expect to have coughing episodes while taking this medication60) A nurse is speaking to a former high school friend. The friend states I heard one of our high school teachers was admitted here, everything okay.” Which of the following responses should the nurse make?1) I recommend you contact the hospital to see if she has been admitted2) I think that you should contact the high school for more information about her3( I can only discuss a status of a client with the clients family4) I cannot discuss the care of anyone who might be hospitalized in our facility61) A nurse is caring for a client who has schizophrenia and is experiencing delusions. The client states, “I can feel worms crawling through my veins.” Which of the following types of delusions should the nurse document the client is experiencing?1) Delusion of persecution2) Erotomaniac delusion3) Delusion of reference4) Somatic delusion62) A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication?1) Prevents the anxiety of abstinence 2) reduces substance craving3) Decrease the likelihood of seizures4) Blocks aldehyde dehydrogenase63) A nurse is caring for a client who is experiencing a panic level of anxiety in the dayroom. After instructing the client to perform deep breathing exercises, which of the following actions should the nurse take next?1) Teach the client about physical manifestations of anxiety2) Discuss methods the client can use to cope with anxiety3) Take the client to an area with fewer distractions4) Encourage the client to discuss the events preceding the panic attack64) A nurse is caring for a client who was just placed in mechanical restraints. Which of the following actions should the nurse take?1) Request that the provider provide an as-needed prescription for restraints2) Withhold food and drink until the restraints are removed from the client3) Offer the client the opportunity to use the toilet every 15 kin while in restraints4) Notify the provider about the use of restraints after the restraints are removed65) A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as a countertransference?1) The client asked me to go on a date with him, but I refused2) The client generally shares his feelings during group therapy sessions3) The client needs to accept responsibility for his substance use4) The client is just like my brother who finally overcame his habit66) A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall the attack. The nurse should identify that the client is using which of the following defense mechanisms?1) Repression2) Reaction formation3) Suppression4) Sublimation Health ScienceScienceNursing MENTAL HEA NUR4445

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