RN Mental Health Flashcards 2023

Questions and Answers

Which of the following findings should the nurse report to the provider as potential adverse effects of sertraline? (Select all that apply)

Insomnia (correct)

Elevated blood pressure (correct)

Decreased sodium level (correct)

Increased temperature (correct)

Diaphoresis (correct)

Headache (correct)

What is the maladaptive use of a defense mechanism demonstrated by the client who is agitated after exercise?

Maladaptive use of a defense mechanism

What is the term for when a client views an exercise instructor as being evil despite having many things in common?

Splitting

Which finding indicates the child is experiencing post-traumatic stress disorder (PTSD)?

Lack of interest in an upcoming holiday Signup and view all the answers

Which finding should the nurse report for a client taking lamotrigine?

Development of a rash Signup and view all the answers

What WBC count indicates a contraindication for receiving clozapine?

WBC count 2,500/mm3 Signup and view all the answers

What statement indicates the client has a decreased risk for suicide?

It is easier to talk about my feelings now. Signup and view all the answers

What assumption should be made based on the client's nonverbal behavior?

The client is interested in what the nurse is saying. Signup and view all the answers

What intervention should be included for a client reporting auditory hallucinations?

Promote the use of music to compete with the client's auditory hallucinations. Signup and view all the answers

What nursing intervention is anticipated for a client who has impaired cognition?

Approach from the front Signup and view all the answers

What information about relapse should be included in discharge teaching for a client with depression?

Early identification of changes, such as decreased social involvement, is important. Signup and view all the answers

Which strategy should be utilized for a client with antisocial personality disorder?

Set realistic limits on the client's behavior. Signup and view all the answers

What manifestation should be included in teaching families about PTSD?

Experiences feelings of isolation. Signup and view all the answers

What action should be taken if a client is pacing with clenched fists?

Ensure security personnel are available in the background. Signup and view all the answers

What situation requires an incident report?

A client was administered one-half of the prescribed dose of medication. Signup and view all the answers

What intervention can reduce anxiety among clients with PTSD?

Guided imagery. Signup and view all the answers

What intervention should be performed for a client with alcohol toxicity?

Gather supplies for endotracheal intubation. Signup and view all the answers

What finding should the nurse expect after cocaine use?

Hypertension. Signup and view all the answers

What action should be taken for a client with bipolar disorder and severe depression?

Move the client who has bipolar disorder to a private room. Signup and view all the answers

At what level of anxiety should relaxation techniques be taught?

Mild. Signup and view all the answers

What adverse effect should be monitored in a child taking methylphenidate?

Tachycardia. Signup and view all the answers

What information should include in teaching about a 12-step program for alcohol use disorder?

The client should obtain a sponsor before discharge. Signup and view all the answers

What intervention should be included in a care plan for a client with bipolar disorder experiencing mania?

Offer the client high-calorie finger foods frequently. Signup and view all the answers

What finding should be expected in a client with borderline personality disorder?

Emotional lability. Signup and view all the answers

What response should be given to an older adult client expressing feelings of punishment from God?

Let's talk about what is upsetting you. Signup and view all the answers

How many mL of diazepam should the nurse administer for a 7.5 mg dose?

1.5 Signup and view all the answers

What finding supports suspicion of delirium?

Easily distracted. Signup and view all the answers

What statement indicates risk for complicated grief?

I feel so empty without my wife that it's hard to get up every morning. Signup and view all the answers

What lab result should be reviewed before administering clozapine?

Absolute neutrophil count. Signup and view all the answers

What action should be included in the care plan for electroconvulsive therapy (ECT)?

Monitor the client's cardiac rhythm during the procedure. Signup and view all the answers

What adverse effect should be reported for a child taking atomoxetine?

Dark urine. Signup and view all the answers

What finding should the partner report for a client with bipolar disorder?

Inability to sleep. Signup and view all the answers

Which client should be assessed first?

A client who is experiencing delusions of persecution. Signup and view all the answers

What manifestation of autism spectrum disorder should be included in teaching?

Language delay. Signup and view all the answers

What secondary prevention strategy should be included for partner violence?

Establish screening programs to identify at-risk clients. Signup and view all the answers

What treatment option offers interdisciplinary services for a client with schizoaffective disorder?

Assertive community treatment. Signup and view all the answers

What statement indicates manipulative behavior?

If you do my homework for me, I won't bother you for the rest of the day. Signup and view all the answers

What finding must be reported due to a threat of harm?

A client with borderline personality disorder threatened to harm their roommate. Signup and view all the answers

What action should be suggested to parents grieving a child?

Suggest forming a weekly support group for parents who have experienced the death of a child. Signup and view all the answers

What therapeutic nursing intervention is the priority for a child with conduct disorder?

Reduce environmental stimuli. Signup and view all the answers

What intervention should be included for an older adult client experiencing delirium?

Permit the client to perform daily rituals to decrease anxiety. Signup and view all the answers

What action exemplifies the ethical principle of justice?

Spending adequate time with a client who is verbally abusive. Signup and view all the answers

What statement indicates an understanding of updating nursing care plans for depressive disorders?

I will update the plan of care as a client's manifestations of depression change. Signup and view all the answers

What action should be taken for a client requiring restraints?

Ensure a staff member checks on the client every 15 minutes. Signup and view all the answers

What finding should be documented as a negative symptom of schizophrenia?

Anhedonia. Signup and view all the answers

What ethical principle applies when transferring a violent client to a different unit?

Nonmaleficence. Signup and view all the answers

What finding indicates the client is experiencing alcohol withdrawal?

Blood pressure 154/96 mm Hg. Signup and view all the answers

What initial action should be taken when a client appears withdrawn and fearful?

Inform the client that this admission is confidential. Signup and view all the answers

What behavior suggests a client has dependent personality disorder?

The client needs excessive external input to make everyday decisions. Signup and view all the answers

What intervention should be included for a client with anorexia nervosa?

Encourage the client to drink 125 mL of fluid each hour while awake. Signup and view all the answers

What immediate action should be taken if a client with acute mania assaults another client?

Call for a team of staff members to help with the situation. Signup and view all the answers

What risk factor for depression should be identified?

The client has COPD. Signup and view all the answers

What findings suggest manifestations of a personality disorder?

Stealing money, anxious if alone, hypersexualization, married multiple times, self-injury, physical altercations. Signup and view all the answers

Which therapies are expected for the treatment of obsessive-compulsive disorder (OCD)?

Systematic desensitization Signup and view all the answers

What medications are appropriate for dementia treatment?

Validation therapy Signup and view all the answers

Which treatment is recommended for borderline personality disorder?

Fluoxetine Signup and view all the answers

What findings confirm consistent health assessment of schizophrenia?

Delusions of grandeur Signup and view all the answers

What findings may indicate maladaptive uses of defense mechanisms for a client with panic disorder?

Excessive reassurance seeking Signup and view all the answers

Study Notes

Trauma and Stress Disorders

Post-traumatic stress disorder (PTSD) can manifest as a lack of interest in activities, e.g., upcoming holidays, particularly in children who have experienced significant loss.
Common clinical manifestations of PTSD include feelings of isolation.

Medications and Side Effects

Lamotrigine use may lead to dangerous rashes which must be reported immediately.
Clozapine treatment requires monitoring for low white blood cell counts (WBC < 2,500/mm3) as it is a contraindication.
Methylphenidate may cause tachycardia, necessitating monitoring in pediatric clients.
Early identification of depressive symptoms, such as reduced social involvement, is vital for preventing relapse.

Clinical Interventions and Relationships

Establishing real limits when communicating with clients exhibiting antisocial personality disorder is crucial for effective engagement.
Nonverbal behaviors, such as maintaining eye contact and leaning forward, indicate a client’s interest in the therapeutic conversation.
For clients with schizophrenia experiencing auditory hallucinations, utilizing music can serve as a beneficial coping strategy.

Ethical and Safety Considerations

Ensuring safety is critical in aggressive situations; having security personnel ready during escalated client behavior is crucial.
Incident reports should be completed for medication administration errors, e.g., administering half the prescribed medication dose.
The ethical principle of nonmaleficence is applicable when transferring clients to units equipped for managing violence.

Assessment and Diagnosis

Symptoms like emotional lability and feelings of fear or withdrawal may characterize borderline personality disorder.
Distinguishing between delirium and dementia can involve noting signs such as distractibility.
Risk factors for depression include chronic illnesses, such as COPD.

Therapeutic Techniques and Support

Encouraging engagement in high-calorie snacks for clients experiencing mania helps address nutritional needs.
Establishing support groups for grieving parents can aid in collective healing after loss.
Risky behaviors such as threats in borderline personality disorder should be communicated to appropriate staff or authorities.

Client Care and Family Education

Family members should be educated on the need for a recovery sponsor in 12-step programs for alcohol disorders.
For clients undergoing electroconvulsive therapy (ECT), it’s essential to monitor cardiac rhythms throughout the procedure.
Teaching parents about autism spectrum disorder may include key manifestations like language delay.

Crisis Situations

In a crisis where a client behaves aggressively, calling for assistance supports safety and intervention.
Prioritizing client assessments in acute mental health settings is essential; those expressing delusions should be seen first.

Long-term Management

Assertive community treatment is ideal for clients with severe schizoaffective disorder, providing necessary support at home.
Regular updates to care plans should reflect changes in clients’ depressive symptoms as they evolve.

Defense Mechanisms in Maladaptive Behaviors

Recognizing maladaptive defense mechanisms such as splitting can help in understanding clients' responses to stressors, especially in panic disorders.

Medication Monitoring

The use of selegiline transdermal patches requires monitoring for potential hypertensive crises, particularly after consuming tyramine-rich foods.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz consists of flashcards designed to help nursing students understand mental health concepts, particularly in relation to post-traumatic stress disorder (PTSD) in children. Each flashcard presents a scenario for nurses to think critically about mental health assessments and interventions.