A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

Dependence on parents to participate in the client’s care

A need for continued intensive monitoring in the home

A decrease in admission frequency to inpatient psychiatric hospitals

A need for crisis intervention services on an ongoing basis

Answer and Explanation

The Correct Answer is C

Choice A reason:
Dependence on parents to participate in the client’s care indicates that the client is not progressing towards independence. Effective in-home mental health care aims to empower clients to manage their own health and reduce reliance on others. Therefore, this response does not demonstrate effective care.
Choice B reason:
A need for continued intensive monitoring in the home suggests that the client’s condition remains unstable and requires constant supervision. Effective care should lead to improved stability and a reduction in the need for intensive monitoring.
Choice C reason:
A decrease in admission frequency to inpatient psychiatric hospitals indicates that the client’s condition is stabilizing and that they are managing their mental health more effectively at home. This outcome demonstrates that the in-home mental health care is effective in reducing the need for hospitalization.
Choice D reason:
A need for crisis intervention services on an ongoing basis suggests that the client continues to experience frequent crises. Effective in-home mental health care should help the client develop coping strategies and support systems to manage their condition, reducing the need for frequent crisis interventions.

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Correct Answer is B

Explanation

Choice A reason:
Neuroleptic malignant syndrome (NMS) is a rare but serious side effect of antipsychotic medications. It is characterized by symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction. The client’s description of needing to move around does not align with the symptoms of NMS.
Choice B reason:
Akathisia is a common side effect of first-generation antipsychotic medications. It is characterized by a feeling of inner restlessness and an urgent need to move. The client’s behavior of pacing and the statement “I just need to move around” are indicative of akathisia.
Choice C reason:
Tardive dyskinesia is a long-term side effect of antipsychotic medications, characterized by involuntary, repetitive movements, particularly of the face and tongue. The client’s symptoms of needing to move around do not match the typical presentation of tardive dyskinesia.
Choice D reason:
Impaired ability to regulate body temperature can occur with antipsychotic medications, but it is not characterized by the need to move around. The client’s symptoms are more consistent with akathisia rather than issues with thermoregulation.

A. Anticipate removing the restraints every 4 hours. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Ensure four fingers fit under the restraints to prevent constriction.

Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

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A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

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Correct Answer is B

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?