ATI Mental Health Practice A with NGN

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? A. Do not administer the lorazepam B. Request a prescription for IV lorazepam C. Request that another nurse attempt to administer the lorazepam D. Place the lorazepam in the client's food

A. Do not administer the lorazepam. Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment. Therefore, the nurse should hold the medication and document the client's refusal.

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? A. "I'm relived now that my financial affairs are in order." B. "It is easier to talk about my feelings now." C. "Suddenly I have enough energy to do anything I want." D. "Thank you for always taking such good care of me."

B. "It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome.

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? A. Have the client participate in a morning aerobics group. B. Encourage frequent rest periods throughout the day. C. Provide a distraction such as television at night. D. Offer the client hot chocolate at bedtime.

B. Encourage frequent rest periods throughout the day. A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.

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. Anhedonia 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 (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? A. Offering self B. Use of silence C. Attention to body language D. Reflection of feelings

C. Attention to body language Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? A. Sore throat B. Photophobia C. Hand tremors D. Constipation

C. Hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? A. Raise the pitch of the voice when speaking to the client. B. Begin the interview by explaining the plan of care. C. Interview the client in a private setting. D. Ask the client to complete a detailed questionnaire.

C. Interview the client in a private setting. The nurse should interview clients in a private place when asking questions regarding client health.

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the 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.

C. Provide frequent high-calorie snacks. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the the A. Controls anger outbursts to avoid being placed in seclusion. B. No longer exhibits a fear of social or public situations. C. Refrains from manipulating others to earn dining room privileges. D. Imitates the therapist's use of a relaxation technique.

C. Refrains from manipulating others to earn dining room privileges. The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? A. The client will take prescribed medications as scheduled. B. The client will express feelings of frustration. C. The client will refrain from self-mutilation. D. The client will participate in group therapy.

C. The client will refrain from self-mutilation. The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the client to refrain from self-mutilation.

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? A. "It will be better for you to keep busy to avoid thinking about your child's death." B. "You will complete the grieving process about a year after your child's death." C. "The grief process will start once your child actually dies." D. "It is not uncommon to feel angry toward yourself or others."

D. "It is not uncommon to feel angry toward yourself or others." Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.

A nurse is caring for a client who has impaired cognition. Nurses' Notes Day 1 0800: Client is able to assist with self-care. Client is easily startled by sudden changes and loud noises. Day 3 0830: Client has wandered into other client's rooms and is more restless at night. Client has increased anxiety and confusion today; does not want to stay seated in the medical recliner. Progress Report 0230: Prior medical record obtained and reviewed. Client has a history of major depressive disorder and has had two prior suicide attempts. Currently lives at a half-way house in town. Last hospitalization was 3 months ago for phenelzine toxicity. Client was changed to selegiline transdermal prior to discharge. Weight at time of discharge was 83.5 kg (184 lb). Vital Signs Day 1 0800: Temperature 36.9° C (98.4° F), Heart rate 92/min, Respiratory rate 26/min, Blood pressure 132/80 mm Hg Day 3 0830:​ Temperature 37.3° C (99

Provide the client with high-calorie protein drinks hourly - Nonessential. This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has mania with this type of dietary supplement. When addressing the client, approach them from the front when possible - Anticipated. A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote aggressive behavior in the client. Ensure the bed is kept at a working height for the nurse - Contraindicat. The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the client does fall. Decrease sensory stimulation - Anticipated. A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair client safety. Keep the lights off in the client's bedroom and bathroom at night - Contraindicated. This can increase the client's risk for falls. Keeping a light on can decrease wandering. Use a vest restraint to keep the client in a medical recliner - Contraindicated. The client has the right to be free from the use of restraints except in the case of an emergency. Give directions to the client slowly and in a moderate tone of voice - Anticipated. Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause the client to feel uncomfortable and can even cause feelings of anger. Assign the client to a room near the nurses' station - Anticipated. This promotes client safety by allowing staff to observe the client frequently.

The nurse is evaluating the client after interventions for alcohol withdrawal syndrome have been implemented. Which of the following findings indicate a positive response to therapy? (Select all that apply.) Respiratory rate Tremors Heart rate Unable to recall the trip to the facility Temperature Withdrawn and quiet upon awakening Blood pressure Slept with minimal disruption for 8 hr

Slept with minimal disruption for 8 hr is correct. One of the major goals for a client who is experiencing alcohol withdrawal syndrome is sedation and rest. The client slept for 8 hr, indicating a positive response to therapy. Blood pressure is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's blood pressure has decreased from 164/82 mm Hg to 124/62 mm Hg, indicating a positive response to therapy. Withdrawn and quiet upon awakening is incorrect. These are manifestations of the client's major depressive disorder and can increase the risk for suicidal ideation. Temperature is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's temperature has decreased from a high of 39.1° C (102.4° F) to 38° C (100.4° F), indicating a positive response to therapy. Unable to recall the trip to the facility is incorrect. Memory blackouts are a manifestation of alcohol withdrawal syndrome. The client's memory remains impaired and unable to recall recent events. Heart rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's heart rate has dropped from 122/min to 95/min, indicating a positive response to therapy. Tremors is correct. Tremors are a manifestation of alcohol withdrawal syndrome. The client's decreased tremor activity is an indication of a positive response to therapy. Respiratory rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's respiratory rate has dropped from a high of 26/min to 22/min, indicating a positive response to therapy.

A nurse on a mental health unit is caring for a recently admitted client. Vital Signs 0800: Blood pressure 110/78 mm Hg, Heart rate 76/min, Respiratory rate 18/min, Temperature 37° C (98.6° F) 1200: Blood pressure 116/80 mm Hg, Heart rate 88/min, Respiratory rate 20/min, Temperature 38° C (100.4° F) Medical History 22-year-old client admitted following episodes of hallucinations and delusions. Outpatient treatment has been ineffective. Client has been unable to maintain a job and friends have said the client has been acting different than usual. Family members have noticed that the client no longer maintains a clean and neat appearance. For each potential assessment finding, click to specify if it is a positive or negative symptom of schizophrenia.

Withdrawal from social activities - Negative Symptoms Alogia - Negative Symptoms Catatonia - Postive Symptoms. Delusions of grandeur - Positive Symptoms. Clang associations - Positive Symptoms. Absence of intonation in speech - Negative Symptoms. Positive symptoms, the presence of symptoms that are not ordinarily present, include hallucinations, delusions, paranoia, and disorganized or bizarre thoughts, behaviors, or speech. Negative symptoms, or the absence of something that should be present, include lack of goal-directed behavior, decrease in participation in social activities, and a flat affect.

A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? A. "I should eat a regular diet with normal amounts of salt and fluids." B. "I should discontinue the lithium when I begin to feel better." C. "I need to be careful to avoid becoming addicted to the lithium." D. "I can skip a dose of medication if my stomach is upset."

A. "I should eat a regular diet with normal amounts of salt and fluids." The nurse should identify that this statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity.

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? A. "If you do my homework for me, I won't bother you for the rest of the day." B. "Mom is always upset." C. "It's not the children's fault. It's mine." D. "It's your fault that we're having problems as a family."

A. "If you do my homework for me, I won't bother you for the rest of the day." This is an example of manipulative behavior. It is an example of manipulation when the family member uses a behavior to get what they desire rather than directly asking for what they want.

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? A. Allow the client time to formulate an answer. B. Prompt the client to give a response. C. Move on to the next client. D. Offer the client a suggestion for a goal.

A. Allow the client time to formulate an answer. Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? A. Arrange one-to-one observation of the client. B. Encourage interaction with the client's peers. C. Administer medication for depressive disorder. D. Encourage the client to attend a support group.

A. Arrange one-to-one observation of the client. The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety.

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? A. Clang association B. Word salad C. Neologism D. Echolalia

A. Clang association The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have a similar sound.

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. Emotional lability Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances.

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to drink 125 mL of fluid each hour while awake. B. Allow the client to eat independently in their room. C. Weigh the client twice weekly. D. Measure the client's vital signs once each day.

A. Encourage the client to drink 125 mL of fluid each hour while awake. The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? A. Promote the use of music to compete with the client's auditory hallucinations. B. Inform the client that the auditory hallucinations are not real. C. Avoid asking the client if they are experiencing auditory hallucinations. D. Instruct the client on the use of voice recognition regarding the auditory hallucinations.

A. Promote the use of music to compete with the client's auditory hallucinations. Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level.

A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? A. Respite care B. Partial hospitalization C. Adult day care program D. Geropsychiatric unit

A. Respite care Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves.

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? A. St. John's wort B. Saw palmetto C. Echinacea D. Ginkgo

A. St. John's wort St. John's wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? 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. The client is interested in what the nurse is saying. The client's posture and eye contact demonstrates an interest in the interview and what the nurse is saying.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? A. "Succinylcholine will enhance the therapeutic effects of this treatment." B. "Succinylcholine is given to reduce muscle movements during therapy." C. "Succinylcholine will decrease the anxiety level that you might experience with this treatment." D. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure."

B. "Succinylcholine is given to reduce muscle movements during therapy." Succinylcholine is a muscle-paralyzing agent that will decrease muscle movement during the procedure so the client is less likely to be injured.

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? A. "You might notice an increase in saliva while taking this medication." B. "You might experience difficulties with sexual functioning while taking this medication." C. "You should expect an improvement in symptoms of depression in 3 to 4 days." D. "You may notice a temporary ringing in the ears when starting this medication."

B. "You might experience difficulties with sexual functioning while taking this medication." Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occur

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? A. A client who has a fasting blood glucose level of 80 mg/dL. B. A client who has a sodium level of 128 mEq/L. C. A client who has a BUN of 18 mg/dL. D. A client who has a potassium level of 3.6 mEq/L.

B. A client who has a sodium level of 128 mEq/L. A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.

A nurse is caring for a group of clients. Which of the following findings should the nurse report? A. A client who is taking clozapine and has a WBC count of 7,500/mm3 B. A client who is taking lamotrigine and has developed a rash C. A client who is taking valproate and has a platelet count of 150,000/mm3 D. A client who is taking lithium and has a lithium level of 1.2 mEq/L

B. A client who is taking lamotrigine and has developed a rash. Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? A. Advise the client to take frequent sips of water. B. Instruct the client to avoid driving during initial therapy. C. Consult a dietitian for a calorie-controlled diet plan. D. Recommend that the client exercise regularly.

B. Instruct the client to avoid driving during initial therapy. The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.

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 toward the client. B. Set realistic limits on the client's behavior. C. Show respect for the client's need for isolation. D. Act as a role model for assertiveness.

B. Set realistic limits on the client's behavior. Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish clear limits on specific aggressive and demanding behaviors.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? A. The client's chart indicates a 1.36 kg (3 lb.) weight gain in 1 month. B. The client reports an inability to breathe easily. C. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. D. The client reports having recently started smoking cigarettes.

B. The client reports an inability to breathe easily. Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? A. The client is exhibiting echolalia. B. The client reports command hallucinations. C. The client reports loss of motivation. D. The client is exhibiting blunted affect.

B. The client reports command hallucinations. The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others.

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? A. A client refuses electroconvulsive therapy after signing the consent form. B. A client who was voluntarily admitted left the unit against medical advice. C. A client was administered one-half of the prescribed dose of medication. D. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.

C. A client was administered one-half of the prescribed dose of medication. An incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form.

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? A. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. B. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. C. A client who has borderline personality disorder threatened to harm their roommate. D. An adolescent client who has anorexia nervosa has a BMI of 17.

C. A client who has borderline personality disorder threatened to harm their roommate. Manifestations of borderline personality disorder include disturbed interpersonal relationships accompanied by threats and other-directed violence. While it is important for the nurse to maintain the client's confidentiality, on occasions when another individual's life might be in danger, the nurse is required by law to report it to authorities.

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a 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 they have questions or concerns about the treatment plan. B. Advise the family member that this treatment plan has been developed specifically for the client to follow. C. Ask the family member if they have any thoughts or questions about the treatment plan. D. Document that the family member does not support the medication treatment plan.

C. Ask the family member if they have any thoughts or questions about the treatment plan. This action involves the family member and allows them a venue to communicate about the client's medication treatment plan.

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? A. Reduced appetite B. Fatigue C. Dark urine D. Sweating

C. Dark urine The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death. Therefore, this is the nurse's priority finding.

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? A. Male gender B. Hyperthyroidism C. Substance use disorder D. Being married

C. Substance use disorder The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

For each of the provider's potential prescriptions, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

CT scan of brain is nonessential. Although a head injury can mimic manifestations of alcohol withdrawal delirium, there is no indication that the client has had a head injury and requires a CT scan. Monitor vital signs every 30 min is anticipated. Vital signs should be monitored frequently to continually assess the client for peripheral circulatory collapse that can occur with alcohol withdrawal. Obtain an Alcohol Use Disorders Identification Test (AUDIT) is nonessential. This screening tool is a self-reporting tool to assist a health care provider with gaining information, which can be used to develop a plan of care. This is not an appropriate prescription for the client at this time, as they are experiencing psychotic manifestations of acute alcohol withdrawal. Initiate IV access is anticipated. Treatment for alcohol withdrawal syndrome requires sedation to prevent seizure activity and circulatory collapse. This is best accomplished for the client via the IV route. Administer an anti-anxiety medication is anticipated. The client is displaying agitation and reporting hallucinations and therefore requires anti-anxiety medication. Wake the client every 30 min for neurological assessment is contraindicated. The treatment plan for this client should include sedation to encourage rest. The client does not require a neurological examination every 30 min.

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's 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 every day, so I don't have a problem."

D. "I am able to go to work every day, so I don't have a problem." By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder.

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? A. "Information regarding clients should remain confidential until after their death." B. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." C. "As long as client identity is disguised, their health information can be shared between professionals on the internet." D. "In the event a client threatens harm to others, medications can be administered without consent."

D. "In the event a client threatens harm to others, medications can be administered without consent." The charge nurse should inform the participants that medications can be administered without consent if a client threatens harm to others. The nurse should always protect the health and safety of their clients, even when a client's safety is threatened by another client.

A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? A. Feelings of remorse B. Extended periods of depression C. Deficits in intellectual functioning D. Aggression toward animals

D. Aggression toward animals The nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take? A. Tell the client that the voices do not really exist. B. Touch the client to help reduce feelings of anxiety. C. Instruct the client to go to a quiet room when the voices start talking. D. Ask the client what the voices are saying.

D. Ask the client what the voices are saying. It is important for the nurse to ask the client directly about the hallucinations to determine if the client or others are at risk for injury.

A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? A. Ensure a family member can be present during treatment. B. Increase fluid intake for 24 hr before the treatment starts. C. Change position slowly when the treatment is complete. D. Avoid looking directly at the light during treatment.

D. Avoid looking directly at the light during treatment. Light therapy, or phototherapy, can cause sensitivity to light. To minimize this effect, the client should avoid looking directly at the light.

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? A. Obtain the weight of a client who has bipolar disorder and is experiencing mania. B. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. C. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. D. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

D. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound.

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? A. Inability to recognize family members B. Chooses clothing that is inappropriate for the weather C. Exhibits a change in personality D. Frequently misplaces objects

D. Frequently misplaces objects According to evidence-based practice, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur.

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? A. Increased confusion B. Sleep disturbances C. Cluttered environment D. Inappropriate dress

D. Inappropriate dress Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? A. Diarrhea B. Heavy menstrual bleeding C. Tachycardia D. Orthostatic hypotension

D. Orthostatic hypotension Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? A. Decrease distractions during meal times. B. Provide positive feedback when the child completes a task. C. Clearly identify consequences for unacceptable behavior. D. Remove unnecessary equipment from the child's surroundings.

D. Remove unnecessary equipment from the child's surroundings. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? A. Confront the staff member. B. Encourage the client to report the incident. C. Document the incident in the client's health record. D. Report the occurrence to the charge nurse.

D. Report the occurrence to the charge nurse. It is the charge nurse and the nurse manager's responsibility to confront the staff member about the derogatory comments made to the client.

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? A. Move the client to a room near the nurses' station. B. Limit visitors until the client is oriented to the environment. C. Tell the client that their partner is deceased. D. Talk with the client about activities they enjoyed with their partner.

D. Talk with the client about activities they enjoyed with their partner. Talking about positive experiences can help distract the client from their disorientation.

A nurse is caring for a client who has alcohol use disorder. Vital Signs 0800: Blood pressure 116/68 mm Hg. Heart rate 80/min. Respiratory rate 14/min. Temperature 36.8° C (98.2° F) 1200: Blood pressure 120/84 mm Hg. Heart rate 96/min. Respiratory rate 20/min. Temperature 37° C (98.6° F) Nurses' Notes 0800: Client alert and oriented to time, place, person, and situation. Visiting with other clients in the dayroom. Attended group session this morning and stated, "I think I'm beginning to see what I need to do to get better." Eager to have family visit with partner later this morning. 1230: Client attended lunch with other clients but refused to eat or drink today. Staring intently at other clients and nursing staff. Posture is rigid and jaw is clenched. Pacing and restless. Complete the following sentence by using the list of options. The client is at greatest risk for Select... as evidenced by the client's S

Drop down 1 Ineffective coping is incorrect. The nurse should continue to monitor the client for ineffective coping and encourage the client to use coping techniques. However, this is not the greatest risk for this client. Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for this client. Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcohol, which is causing them increasing agitation. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury. Drop down 2 Agitation is correct. The client is at greatest risk of engaging in violent behavior as evidenced by the client's agitation, which can be indicated by pacing, restlessness, staring, silence, rigid posture, and clenched jaw. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury. Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for the client. Loss of appetite is an expected finding for a client who is experiencing alcohol withdrawal. Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to perform simple tasks and encourage use of coping strategies. However, this is not the greatest risk for the client.

A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a selegiline 12 mg transdermal patch once daily. Nurses' Notes Tuesday: Client diagnosed with major depressive disorder 15 years ago. Visits clinic twice a week for outpatient group therapy with social worker and follow-up with nurse. Client actively participates in therapy. Acknowledges that relationship with family members has improved and there are fewer verbal altercations. Thursday: Client presents with irritability, diaphoresis, and severe headache, and states, "I am really feeling bad. My heart is pounding." Was excited to share they had met a friend for lunch before coming to the clinic. "Maybe it's something I ate, but we both had the same thing - corned beef sandwich with Swiss cheese. Do you think it is food poisoning?" ​ Vital Signs Tuesday:​ Temperature 37° C (98.6° F) Blood pressure 114/78 mm Hg. Heart rat

Dropdown 1 Extrapyramidal side effects (EPS) is incorrect. EPS are movement disorders caused by first-generation antipsychotic medication. Selegiline is not an antipsychotic medication. Hypertensive crisis is correct. Selegiline is a MAOI medication used to treat depression. Foods that contain tyramine, such as aged cheese, yeast, and smoked or aged meats should not be consumed because this can cause a hypertensive crisis. Other manifestations of hypertensive crisis include chest pain, severe headache, nausea and vomiting, tachycardia, palpitations, and fever. Dry mouth is incorrect. Dry mouth is an anticholinergic reaction due to taking a tricyclic antidepressant. Selegiline is not a tricyclic antidepressant. Dropdown 2 Taking an antipsychotic medication is incorrect. Antipsychotic medications, such as a first-generation antipsychotic, can cause extrapyramidal side effects. Selegiline is not an antipsychotic medication. Anticholinergic reaction is incorrect. An anticholinergic reaction can be caused by taking an SSRI. Selegiline is not an SSRI. Consuming foods high in tyramine is correct. The nurse should identify that consuming foods high in tyramine while taking an MAOI can lead to a hypertensive crisis. Selegiline is a MAOI medication used to treat depression. Foods that contain tyramine, such as aged cheese, yeast, and smoked or aged meats should not be consumed. Other manifestations of hypertensive crisis include chest pain, severe headache, nausea and vomiting, tachycardia, palpitations, and fever.

Complete the following sentence by using the lists of options. The nurse should first Select..., followed by Select....

Dropdown 1 Initiate suicide precautions is correct. The greatest risk to this client is self-injury. Therefore, the first action the nurse should take is to initiate suicide precautions. The client has a history of self-injury and indicates that they have had recent thoughts of harming themselves. Repeat the blood glucose level is incorrect. Repeating the blood glucose level is important for monitoring the glycogen stores of the client. However, there is another action the nurse should take first. Monitor vital signs every 30 min is incorrect. The nurse should monitor the vital signs at least every 30 min. However, there is another action the nurse should take first. Dropdown 2 Administering acetaminophen is incorrect. Hyperthermia is a complication of alcohol withdrawal syndrome. The client's temperature has steadily risen and should be addressed and reduced. However, the nurse must initiate IV access before the medication can be administered. Administering diazepam is incorrect. Diazepam is used during alcohol withdrawal to allow the client to relax and rest. However, the nurse must initiate IV access before the medication can be administered. Initiating IV access is correct. The client has multiple manifestations of alcohol withdrawal syndrome. The primary treatment goal is to provide sedation and IV fluids. Therefore, the nurse must initiate the IV access before these medications can be administered.

Complete the following sentence by choosing from the lists of options. The client is at risk for developing Select... as evidenced by the client's Select....

Dropdown 1 Respiratory distress is incorrect. The client has an oxygen saturation of 96%, which is within the expected reference range. The client's respiratory rate has improved from 11/min to 20/min, so the risk of respiratory distress has resolved. Alcohol withdrawal syndrome is correct. The client had clear evidence of alcohol toxicity, including a BAC of 340 mg/dL. There has been no further alcohol intake since admission to the facility, increasing the client's risk for developing alcohol withdrawal syndrome. Aspiration is incorrect. This client is no longer displaying risk factors for aspiration. Level of consciousness (LOC) is no longer depressed from the alcohol toxicity, and the client is no longer vomiting. Dropdown 2 Heart rate is incorrect. Upon awakening, the client's heart rate has increased to 90/min, which is still within the expected reference range of 60 to 100/min. Mental status is correct. A client who has had an abrupt cessation of alcohol intake will exhibit hand tremors and mental status changes, including agitation, irritability, and anxiety. These are all manifestations of alcohol withdrawal syndrome. Pulse oximetry is incorrect. This client's pulse oximetry is within the expected reference range and does not indicate respiratory distress.

A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) Feelings of hopelessness Pressured speech Grandiosity Anhedonia Flat facial expression

Feelings of hopelessness is correct. The nurse should document feelings of hopelessness as a clinical manifestation of major depressive disorder. Pressured speech is incorrect. This clinical manifestation is associated with clients who are experiencing mania, rather than major depressive disorder. Grandiosity is incorrect. This clinical manifestation is associated with clients who are experiencing mania, rather than major depressive disorder. Anhedonia is correct. The nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorder. Flat facial expression is correct. The nurse should document a flat facial expression as a clinical manifestation of major depressive disorder.

A nurse in the emergency department (ED) is admitting a client who was dropped off at the front door. Nurses' Notes 0200: Client is difficult to arouse, is unable to report on recent events, and is unaware of arrival to ED. Evidence of emesis on clothing. Client reports nausea and has vomited two times since arrival. Odor of alcohol on breath and clothing.Client connected to cardiopulmonary monitoring. Alarms set. 0210: Provider updated and prescriptions received.​ Graphic Record 0200: Temperature 35.6° C (96° F). Heart rate 62/min. Respiratory rate 11/min. Blood pressure 90/56 mm Hg. Oxygen saturation 95% on room air. Weight 74.8 kg (165 lb). Glasgow coma scale (GCS) 13 (3 to 15) Diagnostic Results 0230: Blood alcohol concentration (BAC) 340 mg/dL (0 to 50 mg/dL). Blood glucose level 82 mg/dL (74 to 106 mg/dL). WBC count 7,400/mm3 (5,000 to 10,000/mm3) Provider's Prescriptions: Obtain blood alcohol concentr

Nausea and vomiting is correct. For a client who has ingested alcohol, nausea and vomiting can be an indication of alcohol toxicity, which can result in an alteration in vital signs. Blood glucose level is incorrect. Hypoglycemia can mimic the manifestations of alcohol toxicity. However, this client's blood glucose level is 82 mg/dL, which is within the expected reference range. Temperature is correct. The client can experience a reduction of body temperature as a manifestation of alcohol toxicity. Level of consciousness (LOC) is correct. A client who has an altered LOC following alcohol ingestion might be experiencing alcohol toxicity. BAC is correct. A BAC of 340 mg/dL indicates alcohol toxicity. This value indicates a critical level. Respiratory rate is correct. A respiratory rate of 11/min is below the expected reference range and can indicate alcohol toxicity in the client. Oxygen saturation is incorrect. An oxygen saturation of 95% is within the expected reference range. GCS score is incorrect. The GCS can measure neurological impairment, which can mimic alcohol toxicity. The client has a score of 13, which indicates there is no neurological impairment. WBC count is incorrect. When assessing a client for alcohol toxicity, other health conditions should be considered. A WBC count of 7,400/mm3 is within the expected reference range and indicates there is no infection in the body.

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa. Vital Signs 6/4/XX (Visit 1): Blood pressure 100/64 mm Hg. Heart rate 62/min. Respiratory rate 16/min. Temperature 36.3° C (97.3° F). Oxygen saturation 98% 6/18/XX (Visit 2): Blood pressure 102/66 mm Hg. Heart rate 56/min. Respiratory rate 18/min. Temperature 36.4° C (97.5° F). Oxygen saturation 99% Diagnostic Results Visit 1: ECG Normal sinus rhythm. Cholesterol 196 mg/dL. Platelet count 155,000/mm3 (150,000 to 400,000/mm3) Visit 2: ECG QT prolongation. Cholesterol 238 mg/dL. Platelet count 140,000/mm3 (150,000 to 400,000/mm3) Nurses' Notes Visit 1: Client reports taking laxatives daily and inducing vomiting 3 or 4 days per week. Client states, "I have always been a nervous person, even as a kid. I feel like I need to be perfect, or everyone will think I'm a complete failure. I can't believe I let myself ga

QT prolongation is correct. The finding of QT prolongation in the client's ECG during the second visit reveals cardiac complications of anorexia nervosa. Changes in electrolyte levels can shorten or prolong the QT interval. This is an indication that the client's condition is deteriorating. Exercise regimen is correct. The client's purchase of exercise equipment and working out twice a day is a new manifestation of anorexia nervosa. This is an indication that the client's condition is deteriorating. Hematemesis is correct. New onset of hematemesis might be caused by esophageal irritation or ulceration due to the increase in the frequency of induction of vomiting. Continued induction of vomiting can cause esophageal rupture. Therefore, hematemesis is an indication that the client's condition is deteriorating. Temperature is incorrect. The client's temperature has remained within the expected reference range. A decrease in body temperature with cool skin is an indication that the client's condition is deteriorating. Laxative use is incorrect. The client's cessation of the use of laxatives is an indication that the client's condition is improving. BMI is correct. The client's BMI decreased between visits, which indicates the client is continuing to lose weight. This is an indication that the client's condition is deteriorating.

For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major depressive disorder. Each finding may support more than one disease process.

Weight change is consistent with major depressive disorder. Clients who have major depressive disorder can experience significant weight loss. A 5% or greater loss in weight in a month is considered significant. Level of consciousness (LOC) is consistent with alcohol toxicity. Alcohol is a psychotropic drug and, when ingested at an excessive volume, can affect a client's mood, behavior, and consciousness. Nausea and vomiting is consistent with alcohol toxicity. A BAC of 150 mg/dL can result in nausea and vomiting. Mental status is consistent with alcohol toxicity and major depressive disorder. Alcohol is a psychotropic drug and can result in decreased thinking ability, impaired judgment, and slowed thinking when ingested. A client who has a history of major depressive disorder can display a diminished ability to think or concentrate and is often indecisive. Respiratory rate is consistent with alcohol toxicity. A client who has a BAC of 300 mg/dL can exhibit a decrease in body temperature, blood pressure, and respiratory rate.