Post Assess MH

A nurse is caring for a client who states that he has abused his son because of the stress caused by his son's mental illness. How should the nurse use the communication tool of 'clarifying' when speaking with this client?
The nurse needs additional information/ validation so w/ appropriate questioning the nurse should be able to get more clear/ detailed information of what client means

What are the legal rights of a person admitted to an inpatient mental health facility?
The right to humane treatment and care like medical and dental care
The right to vote
The right to due process which includes the right to press legal charges against another person

A nurse is completing a physical assessment on a child. What are three (3) potential signs of neglect?
Neglect of Physical care like feeding
Neglect of Emotional care like interacting with interacting with child/ stimulation necessary for child development, education of child like enrolling in school
Neglect of needed health or dental care

A nurse is preparing an in-service on child abuse. What clinical findings should the nurse include in this educational session regarding infants?
Shaken baby syndrome which can cause intracranial hemorrhage, check respiratory distress, bulging fontanels, and increased head circumference
Retinal hemorrhage may be present
Any bruising on an infant before 6 months of age is suspicious

A male client is contemplating suicide. Identify three (3) risk factors that increase a client's risk for suicide?
Adolescent, young adult, older males
Comorbid mental illness, depressive disorder, anxiety disorder, substance abuse, schizophrenia, personality disorder
Untreated depression, alcohol/ substance abuse
Family history of suicide, loss of la loved one, physical disorders, sense of hopelessness, intense emotions, developmental stressors

A nurse is caring for a client newly diagnosed with generalized anxiety disorder (GAD). The client asks the nurse how GAD is defined and what common manifestations of this disorder are. What information should the nurse provide?
Generalized anxiety disorder- client exhibits uncontrollable excessive worry for more than 6 months
Fatigue, restlessness, problems w/ concentration, irritability, increased muscle tension, sleep disturbances
Relaxation techniques, instill hope for positive outcomes, identify defense mechanisms, education after anxiety subsides

A nurse is caring for a client diagnosed with both borderline personality disorder and bulimia. What are common characteristics associated with these mental health illnesses?
Instability in identity and relationships, fear of abandonment, splitting behaviors, manipulation, impulsiveness, often tries self mutilation/ may be suicidal, feelings of ineffectiveness, helplessness, depression, distorted body image

A nurse is caring for a client prescribed atomoxetine (Strattera) for the treatment of attention deficit hyperactivity disorder (ADHD). Identify three (3) potential adverse effects of this medication. List associated nursing interventions that should be taken to address these adverse effects.
Appetite suppression, weight loss, growth suppression
GI effects, N/ V
Suicidal ideation and hepatotoxicity
Monitor weight, administer medication before meals, encourage healthy eating, take w/ food, monitor for signs of depression, report signs of liver damage to provider

How does the pharmacologic action of SSRIs and TCAs differ?
TCAs block reuptake of NE and serotonin in the synaptic space and intensify the effects of those neurotransmitters
SSRIs selectively block reuptake of monoamine neurotransmitter serotonin in the synaptic gap intensifying the effects of serotonin

A client has been prescribed Chlorpromazine (Thorazine). What education regarding sun exposure should be provided to this client?
Advise clients to avoid excessive exposure to sunlight, to use sunscreen, and wear protective clothing