PN Mental Health Online Practice Form B Answers With Rationale Graded A+

PN Mental Health Online Practice Form B Answers With Rationale Graded A+

A nurse is caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse report to the charge nurse?
a. a client who has schizophrenia is communicating using echolalia
b. a client who has depression is exhibiting anergia
c. a client who is manic has been pacing the unit for several hours
d. a client who has a phobia is using thought stopping - c. a client who is manic has been pacing the unit for several hours
-the nurse should identify that excessive physical activity in a client who is experiencing a manic episode places the client at risk for physical exhausting and possible death. The nurse should report this client's behavior to the charge nurse.

A nurse is collecting data from a client who is taking valproic acid for treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider?
a. drowsiness
b. nausea and vomiting
c. constipation
d. bleeding gums - d. bleeding gums
-when using the urgent vs non urgent approach to the client care, the nurse should determine that the priority finding is bleeding gums because of the risk of thrombocytopenia.

OR---------

Yellow sclera

Rationale: priority finding is yellow sclera because of risk for hepatotoxicity.

A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next?
a. discuss information about the dilemma with the client's provider
b. determine the benefits and consequences of respecting the client's medical decisions
c. reflect on the effect of ethical theories on the nurse's personal values
d. develop a plan that balances both the nurse's values and the client's medical decisions - b. determine the benefits and consequences of respecting the client's medical decisions
-The first action the nurse should take using the nursing process is to collect data from the client. After the nurse collects the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the client's medical decisions as the next step in the ethical decision-making model.

A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?
a. weigh the client at night prior to bedtime
b. offer liquid supplements to the client
c. encourage the client to gain 2.3 kg (5 lb) per week
d. observe the client for up to 30 min after meals - b. offer liquid supplements to the client
-the nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when he is first admitted.

A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and begins throwing objects at staff and other clients. After calling for assistance, which of the following actions should the nurse take next?
a. obtain a prescription for mechanical restraints
b. place the client in a monitored seclusion room
c. tell the client calmy to sit down
d. administer diazepam intramuscularly - c. tell the client calmly to sit down.
-when providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should use verbal de-escalation techniques after calling for assistance for a client who is aggressive.


A nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse take to demonstrate modeling as a behavioral intervention strategy?
a. setting a time limit between episodes of hand hygiene
b. reminding the client to shout "stop" each time she has an urge to perform hand hygiene
c. demonstrating performing hand hygiene at appropriate times
d. instructing the client to practice muscle relaxation when she has the urge to perform hand hygiene - c. demonstrating performing hand hygiene at appropriate times
-This action is an example of modeling, which is a strategy that allows the client to see another person perform the expected behavior.