The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said that he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?

Efforts to cut down, annoyance w/questions, guilt, drinking as an "Eye-opener"

A female client engages in repeated checks of door and window locks and behavior prevents her from arriving on time and interfering with her ability to function effectively. What action should the RN take?

Plan a list of activities to be carried out daily.

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications includes inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the client?

Blood pressure

a client with schizophrenia receives a prescription for fluphenazine. which instruction is most important for the nurse to include when teaching the client about this drug?

Notify your HCP immediately if involuntary movement develop

The nurse is planning the care for a client who is hospitalized with bipolar disorder. The client wanders the hallways talks sextual comments about staff. Which intervention should the nurse include in the plan of care?

assign client to single room

give concise and firm directions for hygiene and dressing

provide tv programs with suspense to keep attention engaged

invite client for a walk when client energy is high

A client admits to a long- standing history of alcohol abuse related to Intimate partner violence During an assessment, which findings should the nurse expect?

Appearance is older than stated age

the nurse plans to use role playing as a therapeutic measure. which individual is most likely to benefit from this type of thereapeutic intervention

An adolescent who is depressed over, not being accepted by peers

the nurse is conducting client assessments in an outpatient psychiatric clinic. which client finding is characteristics of illness anxiety disorder

Increased talkativeness and pressure to keep talking

A female client with bulimia is admitted to the mental health unit after she discloses to a friend that she purges what should the nurse implement first

Assess weight, vital signs, potassium, and other electrolytes

During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thought. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. What outcome is appropriate based on the action of the nurse?

The nurse and therapist will be asked to educate other team members on appropriate sharing of client information

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the practical nurse (PN) use to demonstrate support of the client?

Schedule regular periods of time for interaction with the client.

The nurse observes a claim with a history of psychosis repeatedly, looking to the side and mumbling to himself. What comment is the best for the nurse to make

You appear to be speaking with someone

A nurse is caring for a client the nurse suspects is the victim of intimate partner violence. What is the nurse’s priority intervention for this client?

Difficulty accepting the explanation about how the injuries totally occurred

A woman who is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave the home because she is afraid of open places and crowds, which nursing problem applied to this clients behavior

Anxiety related to real or perceived threat to physical integrity

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?

Acute confusion

A female client who is a retired school teacher is admitted for breast biopsy. After being told that the biopsy was positive for cancer she becomes dependent, and ask her family for help with activities of daily living, that she is physically capable of performing which interpretation of the clients behavior by the nurse is likely to be most accurate.

Expect as the client is attempted to reduce anxiety by regressing to a state of laser anxiety

A middle-aged adult, with major depressive disorder suffers from psychomotor retardation, hyper, insomnia, and motivation, which intervention is likely to be most effective and returning the client to a normal level of functioning

Teaching the client to develop a plan for daily structure activities

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for Neuroleptic Malignant Syndrome which information is most important for the nurse to obtain during the visit

Current vital signs

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

Reduce the noise level in the room by turning off the television and the radio

A male client with severe anxiety becomes diaphoretic and complains of chest pain, what intervention should the nurse implement first?

Determine the client's pulse and blood pressure

The nurse documents that a male client with schizophrenia is delusional which statement supports the nurse is finding

The nurse at night is trying to poison me with pills

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Focus on small, achievable task, non-taxing problems

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Observe for signs of possible psychosis.

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

The nurses ability to directly observe the clients nonverbal communication is limited with note taking

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Stimulation and dilated pupils

A male client is transferred to a psychiatric facility, following release from the hospital to develop a therapeutic relationship with this client which information is most important

The nurse is feeling about this client

A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. the nurse notices needle marks on the clients arms & plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

Agitation, sweating, & abdominal cramps

The nurse is caring for a client who is a refugee from another country and who is experienced daily episodes minimally with the nurse. We’re going away from an appearing distress which intervention is most important for the nurse.

Reinforced personal strength observed in a client

A client is admitted to the mental health unit & sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, & resists talking. What action should the nurse implement?

Attempt to ask the client simple questions

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Provide for personal space

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

Weight gain of 75 pounds

A client with depression who is taking a tricyclics antidepressant (TCA) reports frequent early morning awakening and difficulty going back to sleep. Which information from the client is important for the PN to obtain to improve the client's sleep pattern?

Take medication upon rising

A clean immense to a long standing history of alcohol abuse related to inmate part of violence during the assessment which findings should the nurse expect

Appearance is older than stated age

A client with schizophrenia receive a prescription for fluphenazine which instruction should the nurse tell this patient about this drug

Notify your healthcare provider immediately if involuntary movement develops

A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nures take

Planning a list of activities to be carried out daily

The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said that he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?

Efforts to cut down, annoyance w/questions, guilt, drinking as an "Eye-opener"

An adolescent comes to the mental health clinic 15 minutes before closing and reports that there is no reason to live. The nurse should

Question the client about any plans for self harm

The client reports to the nurse of taking more than the prescribed dose of alprazolam each day after counseling the patient and adhering to the prescription dosage, which observed behavior should alert the nurse to the safety of the client in

Slurred speech and abnormal gate

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Explore changes in life that have occurred after the loss.

An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?

Sleep at least six hours a night