NUR 348; MH Nursing: ATI Exam I Practice Questions

Lithium case study

apriprazole & NMS

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

"Are you thinking of harming yourself?"

A nurse is talking with a client who states, "The nurses around here are incompetent." Which of the following responses should the nurse make?

"Could you tell me about a specific example of a nurse being incompetent?" Rationale: With this response, the nurse is demonstrating the therapeutic communication technique of clarifying. Without first clarifying the situation, the nurse might not choose the best approach to de-escalating the client's anxiety

A nurse is caring for an older adult client who is scheduled to undergo surgery for a hip fracture. The client says, "I guess I've lived long enough, and now it's my time." Which of the following responses should the nurse make?

"Do you feel that your life ending?" Rationale: This is a therapeutic response because the nurse is using restatement to promote communication, which addresses the client's immediate concern about not living any longer.

A nurse is teaching the family of a client with Alzheimer's Disease about donepezil. Which of the following statements should the nurse include in the teaching?

"Donepezil can improve cognitive functioning during the earlier stages of the disease" Rationale: The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe Alzheimer's Disease, it is intended to prolong the client's ability to function in the early stages of Alzheimer's.

A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique of reflection?

"It sounds like you are concerned about your family's reaction." Rationale: In a reflective response, the nurse directs the feelings and statements back to the client, allowing the client to think about personal feelings.

A nurse is caring for a 13-year-old female client who is admitted for an emergency appendectomy. While the nurse is providing perioperative teaching, the client asks, "Will I have a large scar from the surgery?" Which of the following responses should the nurse make?

"It will be small enough that it won't show when you're wearing a bathing suit." Rationale: This is a therapeutic response that provides information specific to the client's concern. The nurse recognizes that body-image is an important issue for adolescents and hopefully this will alleviate any anxiety she is having about the procedure.

A nurse is teaching a client who wants to stop smoking by using nicotine lozenges. Which of the following statements should the nurse make?

"Limit your use to no more than 20 lozenges per day" Rationale: The nurse should instruct the client that users should consume no more than 5 lozenges within 6 hours and should not have more than 20 lozenges per day

A nurse is teaching a client who has bipolar disorder about lithium. which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience vomiting or diarrhea"

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

"What are the voices telling you to do?"

A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food. "Which of the following statement should the nurse make?

"You seem to be having very frightening thoughts"

A nurse is providing a teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching?

"You should have your white blood cell count checked once per week for 6 months." Rationale: The nurse should instruct the client to have laboratory testing of WBCs and neutrophils ever week for 6 months.

A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

Administer the morning dose of lithium.Rationale: The nurse should administer the lithium dose since a lithium level of 1.0 mEq/L is within the expected initial therapeutic range of 0.8 to 1.3 mEq/L. At a therapeutic level the client might demonstrate adverse effects of lithium, such as a fine hand tremor, thirst, and mild nausea, and the nurse should note if any of these manifestations are present. The nurse should continue to monitor for adverse effects and signs of toxicity, which usually occur at levels of 1.5 mEq/L or higher.

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Adopt a neutral attitude when providing care

A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes anxious and must quickly inside. The nurse should identify what the client is exhibiting which of the following disorders?

Agoraphobia Rationale: Agoraphobia is the fear and subsequent avoidance of places or situations from which escape might be difficult. The most common manifestations of this disorder are a fear of leaving home and avoiding open public places, such as shopping malls

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision?

Apply moistened sterile gauze to the site

A nurse is caring for a client who has schizophrenia & is experiencing a hallucination. Which of the following action should the nurse take next?

Ask the client direct questions about the hallucination

A nurse is admitting an older client who has COPD. The client's daughter is present and states her father will become uncooperative if he is not able to follow his usual routines. Which of the following actions should the nurse take?

Ask the daughter what routines her father follows at home Rationale: The nurse is asking relevant questions to seek more info in order to address the daughter's concerns. The nurse is providing general leads to encourage communication.

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following action should the nurse identify as the priority?

Assign a staff member to stay with the client at all times

A nurse is observing a client with schizophrenia in the dayroom. Another client asks is several items of clothing match. He replies, "A match. I like matches. They are givers of light, the light of the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations?

Associative looseness Rationale: The client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first?

Attempt to reduce environment stimuli Rationale: The nurse should apply the least-restrictive priority-setting framework, which assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize the client's safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff members, or others is at risk. Therefore the nurse should first attempt to calm the client by decreasing environmental stimuli. The nurse should walk with the client to a quiet area that places distance between him and other clients and keeps him away from objects he could use to hurt himself or others. The nurse could ensure that the area is visible to other staff members in case more restrictive measures become necessary.

A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect?

Blurry vision Rationale: Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria

A nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy?

Demonstrating performance of hand hygiene at scheduled times Rationale: This action is an example of modeling, which is a behavior intervention strategy that allows the client to see the expected behaviors performed by the nurse.

A nurse is providing support for the parent's of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first?

Denial Rationale: Evidence-based practice indicates the nurse should first expect the parents to experience denial. Denial is followed by anger, bargaining, depression, and finally acceptance

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client?

Denial Rationale: The nurse should expect to deny the reality of the diagnosis initially. This is a protective reaction that distances the client from psychological pain.

A nurse is organizing a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nurse plan to include during the orientation phase of group development?

Determine the rules that the group will follow Rationale: During the orientation phase of group development, the nurse should determine the rules that apply to the group and ensure that all members understand these rules. Examples of rules to be discussed include confidentiality and meeting times.

A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take?

Document the client's behavior every 15 minutes while restraints are in place Rationale: The nurse should plan to document the client's behavior every 15 minutes while restraints are in place to meet the legal requirement for use of restraints. This documentation allows prompt identification of complication related to restraint use and helps ensure that restrains are removed as soon as possible, depending on the client's behavior.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Experiencing diarrhea Rationale: Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the level of lithium in the blood becomes too high. A low sodium level, or factors which result in a low sodium level, (such as dehydration, diarrhea, sweating, excess exercise in hot weather, diuretic use, a low sodium diet) increases the lithium level because the kidney processes sodium and lithium in the same way. If sodium levels fall, the body conserves lithium, causing lithium levels to rise.

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of behavior of playing a staff member against another. Which of the following actions should the nurse take?

Explore with the client his use of clinging and distancing behaviors Rationale: Splitting is a common defense mechanism demonstrated by clients who have BPD in which the client plays one staff member against another. First, the client expresses feelings of attachment toward a certain staff member and then abruptly begins issuing complaints about this person to other staff members. The underlying cause of splitting is the fear of abandonment and an inability to accept both positive and negative feelings towards others.

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides the surgery?" Which of the following responses should the nurse make?

Have you discussed other treatment with the provider?

A nurse is assessing a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline?

Impaired recent memory Rationale: Short-term memory is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality.

A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?

Institute consequences for manipulative behavior

A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me!" The nurse responds, "I understand, but it is time for group therapy and we expect everyone to attend. Let's walk over together." For which of the following reasons is the nurse's response considered therapeutic?

It clearly articulates what is expected of the client

A nurse is planning care for a client who has completed detoxification from opioid abuse disorder. The nurse should plan to teach about which of the following medications?

Naltrexone Rationale: The nurse should plan to educate the client on the medication naltrexone, an opioid antagonist that is used for the long-term maintenance of opioid use disorder. Nalotrexone is the usual medication choice following detoxification from opioids.

A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching?

Obtain a daily weight. Rationale: Clients who are taking lithium should monitor their daily weight due to the risk of fluid imbalance.

A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect?

Rapid fluctuation in level of consciousness Rationale: A rapidly fluctuating level of consciousness is an expected finding for a client who has acute delirium

A client in a clinic setting tells the nurse, "I haven't seen my son for 2 weeks." The nurse replies, "Your son has not come to see you for 2 weeks?" This is example of the nurse using which of. the following therapeutic communication techniques?

Restating Rationale: By restating the general idea of the client's message, the nurse allows the client to clarify what he meant in case the nurse misunderstood what was said

A nurse is assessing a school-aged child who has ADHD and has been taking desipramine. Which of the following adverse effects should the nurse expect the child's parent to report?

Sedation Rationale: The nurse should recognize that tricyclic antidepressants can cause sedation, along with other anticholinergic effects. Therefore, the nurse should expect the parent to report that the child has been sedated.

A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone?

The abnormal involuntary movement scale

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

The client has a co-occuring borderline personality disorder

The nurse is assessing a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamines?

The client reports eating excessively Rationale: When amphetamine is taken at a therapeutic dose, it cause appetite suppression. Abrupt withdrawal of amphetamine can result in abstinence syndrome in a client who is physically dependent on the medication. Indications of physical dependence include excessive eating, exhaustion, depression, prolonged sleep, and a craving for more amphetamine.

The nurse reviews the laboratory report for a client who is receiving lithium three times daily PO; Blood lithium level is 1.8 mEq/L. Is this a normal lab value?

The lithium level is at a toxic level

The nurse is providing teaching to the parents of an adolescent who has a depressive disorder and a new prescription for trazodone. What is one aspect of client education that should be included?

Trazodone can cause suicidal thoughts in adolescents

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

Vomiting is an indication of toxicity."Rationale: Since vomiting and diarrhea are early signs of lithium toxicity, the client should omit the next dose of lithium and call the provider.

Respiratory depression 2 actions & 2 parameters to monitor

adminster naloxone & couch/deep breath monitor oxygen saturation levels & respiratory rate + depth

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

affective flattening

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor

airway patency

A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

an adult client following a suicide attempt

A nurse is admitting a client to the PACU. Which of the following actions should the nurse take first?

check the client's airway

A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?

dialectical behavioral therapy

When caring for a client who has severe manifestations of schizophrenia and is medicated PRN with haloperidol for agitation, monitor for

dysrhythmias

A nurse is planning to administer haloperidol to a client who has acute psychosis. The nurse should monitor the client for which of the following findings as an adverse effect of the medication?

dystonia

A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that the client is not arousable during which of the following types of anesthesia?

general anesthesia

A nurse is assessing for the presence of EPS, these can include

muscle spasms of the neck fidgeting behavior tremor of the hands

A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine which of the following is the priority risk factor for suicide completion?

previous suicide attempt

A nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an antipsychotic medication. The provider and nursing staff suspect the client is not adhering to his medication therapy. Which of the following interventions should the nurse use to encourage the client's adherence?

provide for once daily dosing use sustained-release forms of the medication engage the client in conversation following medication administration

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

the client who runs 4 miles outdoors everyday

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

yellow-green drainage on the surgical incision