ATI Mental Health
The nurse is planning discharge teaching with a family member of a client with depression. which of the following about relapse should the nurse include? A. Additional acute episodes of depression are unlikely following inpatient care B. Early identification of changes, such as decreased social environment, is important. C. Medication compliance will prevent further need of inpatient care D. It is helpful to regularly reinforce to the client that things will get better.
B- Correct
A nurse is teaching a partner of a client that has bipolar disorder how to identify manifestations of acute mania. Which of the following should the clients partner report to the provider? A. Obsession attention to detail B. Inability to sleep C. Reports of fatigue D. Isolation from others
B- Correct Other s/s of mania: inability to pay attention to detail, unawareness of fatigue, excessive joking and interaction
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? A. Sedation B.Rhinorrhea C. Bradycardia D. Hypothermia
B- Correct Other s/s of opioid withdrawal include: Insomnia, tachycardia, flu-like symptoms, abdominal pain, and hyperthermia
A nurse is assessing a client who recently used cocaine. The nurse would expect which of the findings? A. Polyphagia B. Hypertension C. Decreased temperature D. Depressed mood
B- Correct S/S of cocaine use: decreased appetite, increased blood pressure, increased heart rate, increased body temperature, increased energy levels, increased metabolism
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include about increasing risk of depression? A. Male gender B. Hyperthyroidism C. Substance abuse disorder D. Being married
C- Correct Other risks for depression: female gender, hypothyroidism, single
A nurse in the emergency department is admitting a client who reports a headache with heart palpitations after having a glass of wine with dinner a couple of hours ago. The client has a history of depression and a blood pressure of 210/105. Which of the following questions should the nurse ask first? A. "Do you have family history of hypertension?" B. "when did you last see your pcp?" C. "What medications are you currently taking?" D. "Do you currently use relaxation techniques for increased stress?"
C- Correct: MAOIs are used for treated depression. If used with tyramine- containing foods (like wine) it can result in hypertensive crisis
A nurse is caring for a client that has borderline personality disorder. Which of the following goals is priority when planning care for this client?
C- Correct: The greatest risk to the client is injury to self and others.
A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication for boundary issues? A. An adolescent family member who questions parental authority B. A family with 3 generations in the same household C. Older children who are responsible for their younger siblings D. Two adults from prior relationships in the same household
C- Correct: This is an example of enmeshed boundaries in which there are no distinction between roles of family members. A- Incorrect: This is normal behavior for this age B- Incorrect: This is frequent occurrence and not an indication for boundary issues D- Incorrect: This is a frequent occurrence and not an indication for boundary issues
Word salad
Complete meaningless and disorganized speech pattern
Neologism
Consists of words made up by the client
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. invasion of privacy B. False imprisonment C. Assault D. Battery
Correct- C
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod. D. A client who has bipolar disorder and paces quickly around the room while talking to himself.
Correct- C A- incorrect: The presence of delusions does not constitute a clear reason for a temporary emergency admission unless they present a danger for the client or others. B- Incorrect: Clinical finding of depression do not constitute a clear reason for a temporary emergency admission unless the client is currently at risk for suicide. D- incorrect: a client who is pacing does not constitute a clear reason for a temporary emergency admission.
A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? A. Fear of abandonment B. Motor and verbal tics C. Hostile behavior D. Language delay
Correct- D
A nurse is caring for an older adult client with dementia who has wondered into the day room looking for her deceased partner. Which of the following actions should the nurse take? A. Move the client to a room near the nurse's station B. Limit visitors until the client is oriented to her environment C. Tell the client that her partner is deceased D. Talk to the client about activities she enjoyed with her partner
Correct- D: Talking about positive memories can help distract the client from her disorientation.
A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following information is appropriate to include in the discussion? (select all that apply) A. The DSM-5 includes client education handouts for mental health disorders B. The DSM-5 establishes diagnostic criteria for individual mental health disorder C. Th DSM-5 indicates recommended pharmacological treatment for mental health disorders D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders.
Correct: B, D, E A-Incorrect: It does not include client education handouts C- incorrect: it does not indicate pharmacological treatment for mental health disorders
Decorticate rigidity
Flexion and internal rotation of upper-extremity joints and legs
Veracity
Honesty when dealing with a client
Decerebrate rigidity
Neck and elbow extension, wrist and finger flexion
Echolalia
The client repeats the word of another person
Beneficence
The quality of doing good; can be described as charity
Anhedonia
inability to enjoy otherwise pleasurable activites
Mood vs affect
mood: emotion affect: objective expression of mood (such as flat affect or a lack of facial expressions)
Milieu Therapy
orienting the client to the physical setting, identifying rules and boundaries of the setting, ensuring a safe environment for the client, assisting the client to participate in appropriate activities
A nurse in a mental health unit should recognize that which of the following are appropriate indications for ECT? (select all that apply) A. A client who is suicidal and in need of rapid treatment B. A client who has recently been diagnosed with severe depression C. A client who has bipolar disorder with rapid cycling D. A client who has mania and has not responded to medication therapy E. A client whose depression is secondary to situational difficulties.
A, C, D- Correct
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by the family indicates manipulative behavior? A. "if you do my homework for me, I wont bother you for the rest of the day." B. "Mom is always upset." C. "It's not the childrens fault its mine." D. "It's your fault we are having problems as a family."
A- Correct
A nurse is admitting a client who has schizophrenia to an acute care facility. When the nurse questions the client regarding his admission, the client states, "I'm red. In the head. I'm going to bed." The nurse should document this as which of the following? A. Clang association B. Word Salad C. Neologism D. Echolalia
A- Correct
A nurse is caring for a client who has substance abuse disorder and was admitted involuntarily. When the nurse attempts to give oral lorazepam, the client refuses and becomes physically aggressive. Which of the following actions should the nurse take? A. Do not administer the lorazepam B. Request IV lorazepam from the provider C. Request that another nurse attempt to give the lorazepam D. Place the lorazepam in the clients food
A- Correct
A nurse is caring for a client with schizophrenia that was prescribed a conventional antipsychotic. Which of the following indicates the nurse should give benzotropine 2mg? A. Shuffling Gait B. Hypotension C. Decreased WBC count D. Blurred vision
A- Correct
During a client's interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and is leaning forward. Which of the following assumptions should the nurse make from the patients nonverbal behavior? A. The client is interested in what the nurse is saying B. The client is attempting to manipulate the nurse C. The client is physically attracted to the nurse D. The client needs to feel accepted by the nurse
A- Correct
A nurse is planning care for an adolescent who has been admitted after a failed suicide attempt. What is the nurses priority action? A. Arrange one-to-one observation B. encourage interaction with clients peers C. Administer medication for depressive disorder D. encourage client to attend support group
A- Correct All others are things the nurse should do, but A is priority
A nurse is performing an admission assessment on a client and notices the client appears withdrawn and fearful. To establish a trusting nurse-patient relationship, the nurse should take which action first? A. inform the client that her admission is confidential B. Introduce the client to other clients in the day room C. Assist the client in facilitating behavioral change D. Determine coping strategies that the client has used in the past.
A- Correct B, C, D are all things the nures should do eventually, but A is FIRST
A nurse is caring for a client experiencing a situational crisis. Which of the following findings should the nurse expect? A. The client recently lost a grandparent in a MVA B. The client's town was hit by a tornado C. The client's youngest son is leaving for college D. The client is ambivalent about her upcoming retirement
A- Correct B- Incorrect: adventitious crisis C- Incorrect: maturational crisis D- Incorrect: maturational crisis
A nurse is teaching a family member and client with alzheimers disease about the new prescription of donepezil. Which of the following statements should the nurse include in the teaching? A. Take this medication at bedtime B. Expect this medication to reverse side effects of Alzheimer's C. If you miss a dose, you can double the next dose D. You can crush this med in applesauce
A- Correct This med should be taken at night, it slows the progression of alzheimers, but does not reverse it. You cannot double a dose. This med can not be cut or crushed.
A nurse is caring for a client in the ED who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take? A. gather supplies for endotracheal intubation B. Administer a beta blocker IV C. position the client in low-fowlers position D. Place a cooling blanket over the client
A- Correct Alcohol toxicity S/S: respiratory depression, cold, hypotension, risk for aspiration
A nurse is reviewing a chart of a client with dissociative amnesia. Which of the following findings should the nurse expect? A. The client was seriously injured while under the influence of alcohol B. The client has a history of panic attacks C. The client chose to drop out of college a few months ago D. The client works a stressful job at an international bank
A- Correct: A traumatic event that causes severe stress is a trigger for dissociative amnesia.
A nurse is caring for a client that has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? A. increased creatine phosphokinase (CPK) B. Increased low-density lipoproteins (LDL) C. Decreased fasting blood glucose (FBG) D. Decreased aspartate aminotransferase (AST)
A- Correct: CPK a muscle enzyme that is released with muscle tissue damage as in cardiomyopathy
A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing the spiritual assessment as part of end-of-life care, which of the following should the nurse implement? A. Discuss spiritual issues in a controversial manner B. Engage in a formal discussion of the client's religious beliefs C. Prompt the client to be specific when asking questions related to his own spirituality D. Offer suggestions based on personal spiritual values
A- Correct: Clients receiving end of life care prefer that discussions of spirituality occur in ordinary conversation.
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? A. Emotional lability B. Self-Sacrificing C. Suspicious of others D. Grandiosity
A- Correct: Emotional lability is the rapid transition from one emotion to another, and is a primary sign of borderline personality disorder. B- Incorrect: This is a sign of dependent personality disorder C- Incorrect: This is a feature of paranoid personality disorder. These clients can also put blame onto others and become hostile and violent. D- Incorrect: This is a feature of narcissistic personality disorder. These clients are also exploitive, sensitive to criticism, and filled with rage
A patient is taking paroxetine for depression and states he also uses herbal supplements. Which herbal supplement interacts adversely with paroxetine? A. St. Johns wort B. Saw palmetto C. Echinacea D. Ginkgo
A- Correct: St Johns wort is an herbal supplement that decreases the reuptake of serotonin. Since paroxetine also decreases reuptake of serotonin, this client would be at risk for serotonin syndrome. B- Incorrect: Saw palmetto is used to treat benign prostatic hyperplasia C- Incorrect: Echinacea is used to enhance immune function D- Incorrect: Ginkgo is used to relieve pain from peripheral arterial disease
A nurse is caring for a client that is taking clozapine. For which should the nurse hold the medication? A. Sore throat B. Constipation for 2 days C. Dizziness when getting out of bed D. The client has gained 3 lbs this month
A- Correct: agranulocytosis Constipation, orthostatic hypotension, and weight gain are side effects of clozapine
A nurse is planning care for a client who is constantly threatening others on the unit. Although the client does not want to leave the unit, the nurse requests to the provider to move the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should nurse apply to this situation? A. Nonmaleficence B. veracity C. justice D. autonomy
A- correct
A nurse is planning care for four clients in a mental health facility. Which of these clients is at greatest risk for injury when performing ADLs? A. A patient with severe alzheimers B. A patient in maintenance phase schizophrenia C. A client with OCD D. A client with dysthymic disorder
A- correct
A nurse is teaching a client who has bipolar disorder and is taking lithium. Which of the following instructions should the nurse include in the teaching? A. Take this medication with food B. Reduce sodium intake to 1,000mg/day C. limit fluid intake to 1,200 ml/day D. Be aware that this medication can be addictive.
A- correct: take with food to avoid GI distress B- Incorrect: eat and maintain adequate sodium intake to prevent toxicity of lithium C-Incorrect: need to consume 2000-3000ml fluid/day with initial treatment D- this is not considered addictive
A nurse in a mental health facility is planning discharge for a client with a long history of alcohol use disorder. Which of the following post discharge activities should the nurse include? A. take the oral medication buprenorphine to prevent alcohol use B. Attending a relapse prevention group several times each week. C. Beginning a methadone treatment at a local center D. Living with her mother who has promised to keep her away from alcohol
B- Correct
A nurse is caring for a client that is experiencing a panic attack. Which of the following actions should the nurse take? A. Orient the client to person, place and time B. Assist the client with deep breathing exercises C. Calm the client by using therapeutic touch D. Have the client sit alone in a quiet room
B- Correct
A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? A. Develop a code word that means "time to go" B. Identify signs of escalation of violence C. Have a predetermined place to go in an event of violence D. Keep a hidden packed bag of necessities
B- Correct
A nurse is teaching the parents of a client about their daughters diagnosis of bulimia nervosa. Which of the following statements by the parents indicates understanding of the diagnosis? A. "This disease will increase our daughters risk for high blood pressure." B. "It is important for our daughter to have regular dental check ups." C. "we need to weigh our daughter daily for several weeks, and then once a week." D. "Bleeding during our daughters period will increase because of this disease."
B- Correct
A nurse is updating the plan of care for a client with bulimia nervosa and notices he is 5% above his ideal body weight. Which of the following should the nurse include in her plan? A. Include a liquid supplement with meals B. Identify patients trigger foods C. Allow the client at least one hour for each meal D. Weigh the client at bedtime each day
B- Correct
A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? A. The program will help the client accept responsibility for his disorder B. The client should obtain a sponsor before discharge for an increased chance of recovery C. The client will need to identify people who contribute to his disorder D . The client will need a prescription from his provider before attending
B- Correct A- Incorrect: The nurse should teach the client that he is not responsible for his disorder, but he is responsible for his recovery C- Incorrect: The nurse should teach the client he cannot blame others for his disorder D- Incorrect: The nurse should facilitate a referral, but a prescription is not needed.
A nurse is teaching a client who has depressive disorder about fluoxetine. Which of the following should the nurse include in the teaching? A. "You may notice an increase in saliva while taking this medication." B. "You may experience difficulties with sexual function while taking this medication." C. "You should expect an improvement of depression within 3-4 days." D. "You should experience weight gain while taking this medication."
B- Correct A- Incorrect: pt may have dry mouth C- Incorrect: It can take 1-3 weeks for improvement D- Incorrect: May experience weight loss
A nurse is caring for a client who was admitted after an overdose of amitriptyline. The nurse should monitor the client for which of the adverse of effects of this medication? A. Loose stools B. Urinary retention C. Fever D. Dyspnea
B- Correct Side affects of amitriptyline: ANTICHOLINERGIC EFFECTS. (constipation, urinary retention)
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? A. Behave in a friendly manner with the client B. Set realistic limits about the client's behavior C. Show respect for the clients need for isolation D. Act as a role model for assertiveness
B- Correct: Clients who have antipersonality disorder can seem to be in control of their behavior, but are manipulative and impulsive, and can suddenly become aggressive and assaultive. A- Incorrect: Clients who have antisocial personality disorder might perceive friendliness as an invitation for manipulative and seductive behavior. This strategy should be used for avoidance personality disorder C- Incorrect: Clients who have antisocial personality disorder do not seek isolation. They show antagonistic behavior towards others, and often have a history of criminal misconduct. This strategy should be used for schizophrenia. D.- incorrect: Clients who have antisocial personality disorder do not lack assertiveness. They tend to act in aggressive and exploitative manner. This strategy should be used for clients who have dependent or histrionic personality disorders.
A nurse is on a medical surgical unit and is assessing a client that sustained multiple injuries 12 hours ago from a MVA. Clients admission blood alcohol level was 325mg/dl. which of the following findings should indicate to the nurse that the patient is experiencing alcohol withdrawal? A. Somnolence B. Blood pressure 154/96 C. Pinpoint glucose D. Blood sugar 210
B- Correct: Physical signs of alcohol withdrawal include HTN, tachycardia, and fever greater than 101 F A- Incorrect: Alcohol withdrawal manifestations include agitation, insomnia, and irritability C- Incorrect: In alcohol withdrawal they may experience profuse sweating and dilated pupils due to activation of the ANS system. D- Incorrect: Medical effects of alcohol withdrawal include hypoglycemia. As the glycogen stores in the liver are depleted from extensive alcohol intake, the body's ability to produce glucose is impaired. As a result, blood glucose levels fall, often requiring parenteral dextrose to be administered. Associated manifestations of hypoglycemia are also seen in clients experiencing alcohol withdrawal, such as shakiness and diaphoresis.
A nurse is caring for a client who is about to undergo ECT and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse. A. "Succinylcholine will enhance the effects of this therapy." B. "It is given to reduce muscle movements during therapy." C. "It will decrease the anxiety level you may feel during the treatment." D. "It is used as a general anesthetic to make sure you are sleeping during the procedure."
B- Correct: Succinylcholine is a muscle-paralyzing agent. Given in this scenario to reduce risk of inury
A nurse is teaching coping strategies to a client experiencing depression related to intimate partner abuse. Which of the following statements by the client indicates understanding of the teaching? A. "I will spend extra time at work to keep from feeling depressed." B. "I will talk about my feelings with a close friend." C. "I will be able to learn how to prevent my partners attacks." D. "I will use meditation instead of using my antidepressant."
B- correct
A charge nurse is developing an educational program on schizophrenia. Which of the following manifestations should the nurse include as a negative symptom of schizophrenia? A. Concrete thinking B. Thought blocking C. Echolalia D. Posturing
B- correct All others are positive symptoms of schizophrenia
A nurse is caring for a client who smokes and has lung cancer. The client reports she is coughing because she has a cold but everyone else has been getting. The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation
B-correct
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the importance of medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take? A. Call the family member to the side to inquire if she has questions or concerns about the plan B. Advise the family member that this treatment plan has been developed specifically for the client below. C. Ask the family member if she has any thoughts or questions regarding the treatment plan D. Document that the family member does not support the medication plan
C- Correct
A nurse in a community health center is teaching families of clients who have PTSD about clinical manifestations. Which of the following should she include? A. Repeatedly talks about the traumatic incident B. Sleeps excessively C. experiences feelings of isolation D. Uses repetitive speech
C- Correct
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists with orienting the client to reality? A. Discourage the client from reminiscing about her past. B. Overlook the clients frustration with communication C. Talk to the client about scheduled daily activities D. Present multiple options when offering the client choices
C- Correct
A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me, and I deserve this horrible sickness!" Which of the following responses should the nurse make? A. "Why do you think you deserve this punishment?" B. "Don't worry about this punishment from God." C. "Let's talk about what is upsetting you." D. "You shouldn't say things that upset you so much."
C- Correct
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the care plan? A. offer the client various choices for food selection B. Assign different nursing personnel for each shift C. permit the client to perform daily rituals to decrease anxiety D. Keep the client with lights dim
C- Correct
A nurse is providing teaching to the partner of a client that is in rehab for alcohol use disorder. Which of the following statements by the patient's partner indicates understanding of the teaching? A. "I will avoid social events until my partner has completed treatment." B. "It is important for me to focus on my partners addiction." C. "I will not take charge of my partners work responsibilities." D. "I want my partner to promise to change addictive behaviors."
C- Correct
A nurse who works with newborns is assessing potential for abuse or neglect. Which of the following family groups should the nurse identify as highest potential for future abuse? A. A child in which both parents are adolescents B. A child whose parents respond indifferently to their newborn C. A family where one or both parents experienced or witnessed violence as a child D. A family in which one or both parents has a developmental disorder
C- Correct
A nurse is talking to a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first? A. Recommend the client shave her hair B. Recommend wearing a scarf to hide her hair loss C. Discuss the importance of hair with the client D. provide information on resources for obtaining a wig
C- Correct A, B, D are all things the nurse should do eventually, but C is FIRST
A nurse is caring for a client that takes methylphenidate. The nurse should monitor the child for which of the following findings as an adverse affect of methylphenidate? A. Weight gain B. Tinnitus C. Tachycardia D. Increased salivation
C- Correct Other adverse effects of methylphenidate: Weight loss, dry mouth
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? A. Delusions B. Neologisms C. Anhedonia D. Echopraxia
C- Correct: Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia, anhedonia, and thought blocking Positive symptoms of schizophrenia usually appear suddenly and are alterations in behavior, perception, speech, and thought. Examples- delusions and an inability to think abstractly, neologisms, echolalia, motor agitation, and echopraxia
A nurse is creating plan of care for a client who is in seclusions for threatening to harm others on the unit. Which of the following should the nurse include in her plan? A. Document the clients behavior every 8 hours B. Limit clients intake to 50ml/Hr C. Renew the prescription every 4 hours D. Toilet the client every 4 hours
C- Correct: Rx needs to be renewed every 4 hours for a maximum 24 hours A- Incorrect: The nurse should document behavior every 15-30 minutes while the client is secluded B- Incorrect: No reason to limit intake D- Incorrect: The nurse should offer to toilet the client every 15-30 minutes
A nurse in a providers office is collecting a health history from a parent of a school-aged girl who is taking atomoxetine. Which of the following adverse effects is the priority for the nurse to report to the provider? A. Reduced appetite B. Fatigue C. Dark colored urine D. Sweating
C- Correct: The greatest risk to the child is liver damage from atomoxetine. Reduced appetite, fatigue, and sweating are all adverse effects of atomoxetine.
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operand conditioning. Which of the following client behaviors indicates effectiveness of the therapy? A. Controls anger outbursts to avoid being place in seclusion B. No longer exhibits a fear of social or public places C. Refrains from manipulating others to earn dining-room privileges. D. Imitates the therapists use of relaxation technique
C- Correct: operant conditioning is to provide positive reinforcement for a desired behavior.
A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar. Which of the following behaviors is priority for the nurse to report to the team? A. calling family members B. Spending time alone. C. Giving away possessions D. excessive crying
C- correct
Who of the following can give informed consent? A. a 17 year old that lives with friends B. A 50 year old that has a blood alcohol level of 0.08 C. A 35 year old with major depressive disorder D. A 65 year old that just received morphine
C- correct
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates active listening? A. Offering self B. Use of silence C. Attention to body language D. Reflection of feelings
C- correct A- incorrect: this is a therapeutic technique to demonstrate genuine interest in the patient B- incorrect: Therapeutic technique to demonstrate willingness to wait for the client's response D- incorrect: therapeutic technique to encourage the client to acknowledge his feelings
A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub. B. The client has a Glasgow Coma Scale score less than 7. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place.
Correct- A B- incorrect: This indicates comatose C- incorrect: This indicates comatose D- incorrect: A client that is stuporous is not alert
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply) A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents."
Correct- A, B, C D is incorrect because asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote memory. E is incorrect because asking the client to identify recent presidents is appropriate to assess cognitive knowledge rather than abstract thinking.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager B. Tell the nurse to stop discussing the behavior C. Provide an in-service program about confidentiality D. Complete an incident report
Correct- B
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all the apply) A. "Client at most of his breakfast." B. "Client was offered 8 oz of water ever hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15mg by mouth at 1000." E. "Client acted out after lunch."
Correct- B, C, D
A nurse in an outpatient entail health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services. B. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder.
Correct- B. All are appropriate, but B is the best answer because assessment is the priority action when using the nursing process.
A client tells a nurse "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention of doing so.
Correct- C
A nurse in a mental health unit is admitting a client who is anxious because he frequently hears voices telling him to what to do. Which of the following actions should the nurse take? A. Tell them the voices don't exist B. Touch the client to help the anxiety C. Instruct the client to go to a quiet room when he hears the voices D. Ask the client what the voices are saying
Correct- D
A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy B. Teach the client appropriate coping mechanisms C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications
Correct- D A- Incorrect: assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention. B- Incorrect: Teaching appropriate coping mechanisms is a counseling or health teaching intervention. C- Incorrect: assessing for comorbid heath conditions is a health promotion and maintenance intervention
A charge nurse is planning a code of ethics teaching for registered nurses. Which of the following information should the nurse include? A. client confidentiality applies until the client dies B. privileged communication protects nurse-to-nurse communication C. The duty to protect third parties requires a nurse to testify about her patient D. The right to treatment ensures individualized care
D- Correct
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief? A. "I wish I had been nicer and more generous to my wife before she died." B. "I told my wife to go to the doctor, but she wouldn't listen to me." C. "I think about my wife all the time when I go on outings with my family." D. "I feel so empty without my wife that its hard to get up every morning."
D- Correct
A nurse is assessing a school age child who has conduct disorder. Which of the following should the nurse expect the child to demonstrate? A. Feeling of remorse B. Extended periods of depression C. Deficits in intellectual functioning D. Aggression towards animals
D- Correct
A nurse is caring for a client in a mental health facility. She hears another nurse using derogatory comments to a client. The nurse should A. Confront the staff member B. Encourage the client to report it C. Document the incident in the clients health record D. Report it to the charge nurse
D- Correct
A nurse is caring for a client whose child has a terminal illness. The client requests information on how to deal with the upcoming loss. Which of the following statements should the nurse make? A. "It will be better for you to stay busy to avoid thinking of your child's death." B. "You will complete the grieving process about a year after your childs death." C. "The grief process will start the day your child actually dies." D. "It is not uncommon to feel angry with yourself or others."
D- Correct
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted
D- Correct A- Incorrect: Alzheimers has a slow onset, delirium is acute B- Incorrect: aphasia is a manifestation of dementia C- Incorrect: confabulation is a manifestation of dementia
A nurse is caring for a client with conduct disorder ad is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is priority? A. Encourage expression of feelings B. Promote attendance at an assertiveness training group C. Assist the client to perform relaxation breathing D. Use a therapeutic hold
D- Correct All others are things the nurse should do, but D is first
The nurse is reviewing the MAR for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse affects? A. Blurred vision B. Orthostatic hypotension C. Dry mouth D. Acute dystonia
D- Correct Blurred vision, orthostatic hypotension, and dry mouth are all adverse effects of chlorpromazine. But acute dystonia is an EPS that is treated with benztropine. Benztropine is an anticholinergic agent
A nurse is teaching the parent of a 10 year old child who has ADHD and a new rx for dextroamphetamine. Which of the following instructions should the nurse include in her teaching? A. "You should expect your child to gain weight while taking this medication." B. "Administer this med 30 minutes before breakfast." C. "You should expect your child to have diarrhea while taking this medication." D. "Administer the last dose 6 hours before bedtime."
D- Correct Other side effects of dextroamphetamine: Weight loss, suppressed appetite, constipation, insomnia
A school nurse is assessing a child who experienced a traumatic loss of a parent 8 months ago. Which of the following should the nurse identify as an indication that child is experiencing PTSD? A. clinging behaviors directed towards a teacher. B. increased time spent sleeping C. intense focus on school work D. Lack of interest in an upcoming holiday
D- Correct S/S of PTSD: detachment, difficulty sleeping, distressed dreams, difficulty concentrating
A nurse is admitting a female client with anorexia nervosa. Which of the following manifestations should the nurse expect upon admission? A. Diarrhea B. Heavy Menstrual bleeding C. Tachycardia D. Orthostatic hypotension
D- Correct other s/s of anorexia nervosa: constipation, amenorrhea, bradycardia
A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over the counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A. lansoprazole B. Naproxen C. Magnesium Hydroxide D. phenylephrine
D- Correct: Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other OTC medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in sever HTN.
A nurse is planning care for a newly admitted client with bipolar disorder. Which of the following is priority action by the nurse? A. schedule the client for group therapy sessions B. maintain consistent rules C. Provide frequent high-calorie snacks D. avoid the use of value judgments
D- Correct: Maslows hierarchy of needs. Adequate nutrition
A nurse in a mental care facility is receiving report at shift change for four clients. Which of the following patient's should the nurse assess first? A. A client that does not recognize familiar people B. A client who cannot verbalize his needs C. A client who is awake and disoriented at night D. A client who is experiencing delusions of persecution
D- Correct: The presence of delusions of persecution indicates that this client is at greatest risk for injury due to the client's belief that a person in power is out to harm him.
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? A. "I put in extra hours at work so I won't think about drinking" B. "I know that wine is good for my heart, so that is why I drink some each evening." C. "I make up for my drinking by taking my partner on nice vacations." D. "I am able to go to work everyday, so I don't have a problem"
D- correct
Stuporous
The client requires vigorous or painful stimuli to elicit a brief response. She might not be able to respond verbally.
Mini-mental state examination (MMSE) tests what?
exam used to objectively assess a client's cognitive status by evaluation orientation to time and place, attention span and ability to count backwards by seven, following commands, ability to write, recalling objects
Negative symptoms of schizophrenia
flat affect, anergia, anhedonia, and thought blocking
Positive symptoms of schizophrenia
usually appear suddenly and are alterations in behavior, perception, speech, and thought. Examples- delusions and an inability to think abstractly, neologisms, echolalia, motor agitation, and echopraxia
