Mental Health Practice 2016 A GOOD q/wexp

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)

14 mL 110 lb x (1 kg/2.2 lb) = 50 kg 50 kg x 0.55 mg = 27.5 mg 27.5 mg x(5 mL/10 mg) = 14 mL

A nurse is preparing to discharge an older adult who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply." A. Occupational therapy B. Meal delivery services C. Speech therapy D. Physical therapy E. Home health services

A, B, D, E An occupational therapist can assist the client to perform ADLs. Meal deliver services are necessary due to the client's difficulty performing ADLs. A physical therapist can assess the client's mobility needs and assist with ADLs. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

A nurse is caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? A. Shuffling gait B. Hypotension C. Decreased WBC count D. Blurred vision

A. Shuffling gait Benztropine is used to treat parkinsonism manifestations, such as shuffling gait.

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.

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? A. "You probably want to hold your baby." B. "I'll stay with you in case you want to talk." C. "I know how you must be feeling." D. "It hurts now, but things will be better soon."

B. "I'll stay with you in case you want to talk." This response indicates the nurse's interest in the client and a desire to understand the client's feelings.

The 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 relieved 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 in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? A. "She works so hard at ballet. Will she still be able to perform?" B. "She won't let me take the trash from her room. I'm concerned about what she has in there." C. "She told me she was tired, so I did her chores for her today." D. "She is happier with her appearance now that she's lost some weight."

B. "She won't let me take the trash from her room. I'm concerned about what she has in there." The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statement indicates awareness of her daughter's behavior.

A nurse assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in affect within 30-60 minutes after taking the medication. B. Greater risk of attempting suicide as affect and energy improve. C. Onset of frequent loose stools. D. Development of physiologic dependence on the medication.

B. Greater risk of attempting suicide as affect and energy improve. An initial response to amitriptyline can develop in one week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is more possible after 1 week of treatment.

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 dizziness or drowsiness. 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 planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to participate in group therapy. B. Instruct the client to avoid napping during the day. C. Offer the client high-calorie finger foods frequently. D. Decrease the client's daily fiber intake.

C. Offer the client high-calorie finger foods frequently. The nurse should frequently offer the client, high-calorie foods that can be eaten while the client is on the go. Client's experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A. An adolescent family member who questions parental authority. B. A family with three generations in the same household. C. Older children who are responsible for their younger siblings. D. Two adults and their children from prior relationships in the same household.

C. Older children who are responsible for their younger siblings. This is an example of enmeshed boundaries in which there are no distinctions between roles of family members.

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 therapy? 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 attempted suicide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism? A. "I will limit my drinking to the weekends." B. "I will stay in my room and avoid others when I'm feeling down." C. "I will be dependent on others for the time being." D. "I will attend daily group therapy sessions to practice relaxation techniques."

D. "I will attend daily group therapy sessions to practice relaxation techniques." Relaxation techniques decrease the risk for self-harm by decreasing stress, anxiety, and depression

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following places the client at the greatest risk for self-directed injury or injuring others? A. Inability to communicate with others B. Feeling of absence of self-worth C. Lack of motivation to perform daily tasks D. Command hallucinations

D. Command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling him to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.

A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? A. Have a family member present during treatment. B. Increase fluid intake. C. Change position slowly. D. Wear sunglasses when outdoors.

D. Wear sunglasses when outdoors. Light therapy, or phototherapy can cause eye strain and sensitivity to light.

A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the following statements indicates that client teaching regarding the medication has been effective? 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." 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 observes a client on a mental health unit pushing on a locked unit door. Which of the following statements should the nurse make? A. "It appears as though you would like to open the door." B. "You will feel more comfortable after you've been here a while." C. "It is okay to not want to be here." D. "You really shouldn't be pushing on the door."

A. "It appears as though you would like to open the door." This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that she can describe thoughts and feelings related to that behavior.

A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer's disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? A. "Take this medication in the evening at bedtime." B. "Expect this medication to reverse the effects of Alzheimer's disease." C. "If you miss a dose, double the next dose." D. "You can crush this medication in applesauce."

A. "Take this medication in the evening at bedtime." The client should take this medication in the evening at bedtime for optimal effectiveness.

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, she does not respond. Which of the following actions should the nurse take before repeating the request to the client? A. Allow the client time to collect her thoughts. 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 collect her thoughts. 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 caring for a client who is experiencing alcohol withdrawal. The client has a heart rate of 110/min, blood pressure of 170/96 mm Hg, and temperature of 38.9 degrees Celsius( 102 degrees Fahrenheit). Client history and physical include that the client states he consumed alcohol 12 hours prior to admission and the client has a 2 pack/day smoking history. Client progress notes include bilateral tremors of the hands and finger, emesis of 30 mL bile-colored fluid, restlessness, unable to sit still, diaphoresis, and flushed skin. Which of the following medications should the nurse administer first? A. Diazepam 5 mg IV bolus B. Clonidine 0.1 mg transdermal patch C. Naltrexone 380 mg IM D. Bupropion 150 mg PO

A. Diazepam 5 mg IV bolus The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations.

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. Graniosity

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 his 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 reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine. A. WBC 2500/mm3 B. Hbg 11.5 mg/dL C. Platelets 150,000/mm3 D. RBC 3.5 million/mm3

A. WBC 2500/mm3 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count below 3000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "That man in my room never sleeps and he keeps me up too." Which of the following is an appropriate action for the nurse to take? A. Move the client who has bipolar disorder to a private room. B. Administer sleep medication to the client who has bipolar disorder. C. Move the client who has severe depression to a private room. D. Administer sleep medication to the client who has severe depression.

A. Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? A. The client needs excessive external input to make everyday decisions. B. The client demonstrates a dedication to his job that excludes time for leisure activities. C. The client adheres to a rigid set of rules. D. The client has difficulty starting new relationships unless he feels accepted.

A. The client needs excessive external input to make everyday decisions. Clients who have dependent personality disorder need excessive input from others to make everyday decisions.

A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following 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. The client was seriously injured while under the influence of alcohol. A traumatic event that causes stress is a trigger for dissociative amnesia.

A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the client's ability to cope with this situation? A. "Don't you think you'll get through this in time?" B. "To whom do you talk when you feel overwhelmed?" C. "Have you thought about rebuilding your home on the same site?" D. "Would you like me to find a therapist for you to speak with?"

B. "To whom do you talk when you feel overwhelmed?" By asking this question, the nurse is assessing the client's support systems, which is an important factor in the client's ability to cope with the situation.

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C. "You don't want to look at yourself because you think you are fat." D. "You and I can work together to overcome your fears of gaining weight."

B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

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 sugar 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 facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? A. Tell the client that he must talk less or he will be removed from the meeting. B. Ask group members to discuss their feeling about this client's monopolizing behavior. C. End the group meeting and take the client aside to discuss his behavior. D. Focus on other group members and ignore the client who is doing all the talking.

B. Ask group members to discuss their feeling about this client's monopolizing behavior. This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

A nurse is caring for a client who 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. Assist the client with deep-breathing exercises. Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hours ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? A. Somnolence B. Blood pressure 154/96 mm Hg C. Pinpoint pupils D. Blood glucose 210 mg/dL

B. Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3 degrees Celsius (101 degrees Fahrenheit). It will be important for the nurse to rule out infection in the client who has a fever.

A charge nurse enters a client's room and observes an assistive personnel (AP) slapping an older adult client. After moving the client to safety, which of the following actions is the charge nurse's priority? A. Complete an incident report. B. Determine if the client has been physically harmed. C. Provide emotional support to the client. D. Discipline the AP.

B. Determine if the client has been physically harmed. The greatesy risk to this client is injury. Therefore, the priority intervention the charge nurse should take is to determine id the client has injuries that need attention.

A nurse is planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention? A. Provide teaching about the use of positive coping mechanisms. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

B. Establish screening programs to identify at-risk clients. This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for intimate partner abuse in the community and take the necessary steps to address individual client needs.

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 individuals who have contributed to his disorder. D. The program will need a prescription from the client's provider prior to attendance.

B. The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client to secure a sponsor because the client-sponsor relationship has been shown to increase program attendance and chances of recovery.

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use the same plan of care and interventions for each client who has depression." B. "Each individual nurse will develop a separate plan of care when managing clients who have depression." C. "I will update the plan of care as a client's manifestations of depression change." D. "An assistive personnel can use the plan of care for client teaching."

C. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change.

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.

During the morning rouns, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? A. Ask the client to identify the bomb in the room. B. Initiate disaster protocols per facility policies and procedures. C. Assess the client for evidence of a perceptual disturbance. D. Convince the client that there is no bomb in her room.

C. Assess the client for evidence of a perceptual disturbance. The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions).

A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who was hit for injuries.

C. Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others.

A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A. Repeatedly talks about traumatic incident B. Sleeps excessively C. Experiences feelings of isolation D. Uses repetitive speech

C. Experiences feelings of isolation Clients who have PTSD often feel estranged and detached from others.

A nurse in a mental health clinic is caring for a client with bipolar disorder and reports that she 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 the client's 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 question clients in a private place when conducting interviews regarding client health.

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? A. Document the client's behavior every 8 hours. B. Limit the client's fluid intake to 50 mL/hour. C. Renew the prescription for the client every 4 hours. D. Toilet the client every 4 hours.

C. Renew the prescription for the client every 4 hours. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hours, for a maximum of 24 hours.

A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take? A. Encourage the parent to avoid discussing the death with other children in order to protect their feelings. B. Recommend each parent grieve in private to avoid hindering each other's healing. C. Suggest forming a weekly support group for parents who have experienced the loss of a child. D. Advise the parents to begin counseling if they are still grieving in a few months.

C. Suggest forming a weekly support group for parents who have experienced the loss of a child. Support groups are a positive resource in the process of recovery for parents who have lost a child.

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? A. Weight gain B. Tinnitus C. Tachycardia D. Increased salivation

C. Tachycardia The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization? A. Weight loss 10% of total body weight in 3 months. B. Potassium 3.8 mEq/L C. Temperature 35.6 degrees celsius (96.1 degrees Fahrenheit) D. Heart rate 54/minute

C. Temperature 35.6 degrees Celsius (96.1 degrees Fahrenheit) Severe hypothermia, a temperature lower than 36 degrees Celsius (96.8 degrees Fahrenheit) due to loss of subcutaneous tissue or dehydration, requires hospitalization.

The nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? A. The client is married. B. The client recently received a promotion at work. C. The client has COPD. D. The client is a male.

C. The client has COPD. Clients who have a medical illness are at an increased risk for the development of depression.

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 nurse's suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted

D. Easily distracted Extreme distractibility is a hallmark manifestation of delirium.

A nurse is caring for a client who has a recent diagnosis of 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 nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery? A. "I consciously decrease my breathing rate when I feel anxious." B. "I am riding my bike around the neighborhood every day." C. "I find at least one positive thing in situations that upset me." D. "I imagine myself lying on a quiet beach when I start to feel anxious."

D. I imagine myself lying on a quiet beach when I start to feel anxious." Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery.

A home 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 planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? A. Panic B. Moderate C. Severe D. Mild

D. Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety, The is when the client will be able to concentrate and process information.

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? A. Administer phenytoin 30 minutes prior to the procedure. B. Instruct the client to expect a headache following the procedure. C. Place the client in four point restraints prior to the procedure. D. Monitor the client's cardiac rhythm during the procedure.

D. Monitor the client's cardiac rhythm during the procedure. The seizure induced during ECT can stress that client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram.

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. Phenylephrine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take Phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority? A. Encourage expression of feelings. B. Promote attendance at an assertiveness training group. C. Assist the client to perform relaxation breathing. D. Reduce environmental stimuli.

D. Reduce environmental stimuli. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to use a therapeutic holding technique to deescalate the behavior and prevent injury.

A nurse is planning care for a preschool-age 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 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 her behavior toward the client.

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? A. Allowing a client to choose which unit activities to attend B. Attempting alternative therapies instead of restraints for a client who is combative C. Providing a client with accurate information about his prognosis D. Spending adequate time with a client who is verbally abusive

D. Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive care.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? A. Amenorrhea B. Lanugo C. Cold extremities D. Tooth erosion

D. Tooth erosion A client who has bulimia nervosa is likely to have dental carries and tooth erosion caused by frequent exposure to gastric acid from vomiting.