Deck 28: Alterations in Mental Health and Cognitive Function

Question 1

The nurse is planning care for a school-age client, who is diagnosed with bipolar disorder and is having suicidal ideations. Which nursing diagnosis is the priority for this client?
1) Powerlessness Related to Mood Instability
2) Social Isolation Related to Disorder
3) Risk for Injury Related to Suicidal Ideas
4) Impaired Social Interaction

Answer 1

3

Question 2

A school-age client is evaluated for depression. Which assessment tool does the nurse anticipate will be used by the psychologist?
1) Denver Developmental Screening tool
2) Revised Children's Manifest Anxiety Scale
3) Parent Developmental Questionnaire
4) Disruptive Behavior Disorder Scale

Answer 2

2

Question 3

A school-age client is prescribed Adderall (amphetamine mixed salts) for attention deficit hyperactivity disorder (ADHD). At which time is it most appropriate for the nurse to teach the parents to administer this medication?
1) At bedtime
2) Before lunch
3) With the evening meal
4) Early in the morning

Answer 3

4

Question 4

The nurse is conducting a health history for a school-age client. The parents of the client tell the nurse that their child has the following behaviors: excessive handwashing, counting objects, and hoarding substances. Based on these assessment findings, which diagnosis does the nurse anticipate for this client?
1) Depression
2) Separation anxiety disorder
3) Obsessive-compulsive disorder
4) Bipolar disorder

Question 5

A 15-year-old female is brought to the hospital by her friends after she fainted at the movies. Her friends told the nurse that she had been sad, withdrawn and this is why they asked her to go to the movies. The girl became "excited and energetic" at the movies and then fainted.
The physician ordered: Lithium, clonazepam and doxepin. One order is Lithium 300 mg PO tid
Medication on hand: Lithium 150 mg/capsule.
Calculate how many capsules of lithium will be given by mouth.

Question 6

An adolescent client diagnosed with attention deficit hyperactivity disorder (ADHD) is interested in playing the drums in the school band. Which action by the nurse is the most appropriate?
1) Recommend the child take private lessons and not join the band.
2) Encourage the child to join the band.
3) Consult with the healthcare provider about allowing participation in band activities.
4) Discourage the child from playing in the band.

Question 7

A child with a profound intellectual disability is admitted to the hospital for an appendectomy. Which IQ does the nurse anticipate to see documented when reviewing this child's medical record?
1) Between 50 and 70
2) Below 20
3) Between 35 and 50
4) Between 20 and 35

Question 8

The family of a preschool-age client diagnosed with an intellectual disability is expressing difficulty with managing the care needs of the child. Which nursing diagnosis is most appropriate for this situation?
1) Hopelessness Related to Terminal Condition of the Child
2) Compromised Family Coping Related to the Child's Developmental Variations
3) Family Processes Dysfunctional, Related to a Child with Intellectual Disability
4) Impaired Parenting Related to Poor Parenting Skills

Question 9

An adolescent client diagnosed with panic disorder is prescribed paroxetine (Paxil), a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse she often takes diet pills because she is trying to lose weight. Which response by the nurse is the most appropriate?
1) "You can continue with the paroxetine (Paxil) and the diet pills."
2) "It is important to stop both the paroxetine (Paxil) and the diet pills."
3) "Discontinue using the diet pills while taking the paroxetine (Paxil)."
4) "You should discuss the safety of these two medications pills with a pharmacist."

Question 10

A nurse is planning preoperative teaching for a school-age client scheduled to have a tonsillectomy. The client has a history of attention deficit hyperactivity disorder (ADHD). Which intervention will the nurse include in the plan of care?
1) Give instructions verbally and use a picture pamphlet, repeating points more than once.
2) Ask other children who have had this procedure to talk to the child.
3) Allow the child to lead the session to gain a sense of control.
4) Play a television show in the background.

Question 11

A nurse is calculating the maximum recommended dose that a school-age client diagnosed with depression can receive for sertraline (Zoloft). The recommended pediatric dose for sertraline (Zoloft) is 1.5 to 3 mg/kg/day. If the child weighs 31 kg, the maximum recommended dose for this child would be ________ mg. Round answer to the nearest whole number.

Question 12

The nurse is planning care for an adolescent client with a newly diagnosed intellectual disability following a traumatic brain injury. Which expected outcomes are appropriate for this client? Select all that apply.
1) The family understands the adolescent's diagnosis.
2) The family understands the specific physical and developmental needs of the adolescent.
3) The adolescent develops self-care skills appropriate to his or her developmental level.
4) The adolescent's family is able to access the necessary community and educational resources.
5) The family's ability to cope with changing needs of the adolescent.

Question 13

A nurse is conducting developmental assessments on several children in the day-care setting. Which child(ren) does the nurse identify as having development delays? Select all that apply.
1) An 18-month-old toddler who is unable to phrase sentences
2) A 5-year-old who is unable to button his shirt
3) A 6-year-old who is unable to sit still for a short story
4) A 2-year-old who is unable to cut with scissors
5) A 2-year-old who cannot recite her phone number

Question 15

The parents of a client recently diagnosed with Down syndrome relate to the nurse that they "feel guilty about causing the condition." Which response by the nurse is the most appropriate?
1) "Down syndrome is a condition caused by an extra chromosome; the cause of it is unknown."
2) "Down syndrome is a condition that is genetically transmitted from both the father and the mother."
3) "Down syndrome is a condition that is carried on the X chromosome, so it came from the mother."
4) "Down syndrome is caused by birth trauma, not by genetics."

Question 16

A nurse is caring for four pediatric clients in the hospital. Which client should the nurse refer for play therapy?
1) An adolescent with asthma
2) A preschool-age child with a fractured femur
3) A school-age child having an appendectomy
4) An infant with sepsis

Question 17

A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission?
1) Take the child on a quick tour of the whole unit.
2) Take the child to the playroom immediately for arts and crafts.
3) Orient the child to the hospital room with minimal distractions.
4) Admit the child to a four-bed unit with small children.

Question 18

A nurse is concerned about the safety of a suicidal adolescent client and wants to be prepared for the use of physical restraints, if necessary. Which action by the nurse is the most appropriate in this situation?
1) Obtain a healthcare provider's order, and follow the institution's policy for use of restraints.
2) Apply the restraints, and then obtain a healthcare provider's order later.
3) Apply the restraints if parental permission is obtained.
4) Ask for the child's permission before applying the restraints.