Practice 4, 5, 6 (Mental Health) Final Test

A nurse is providing information to a client about risk factors for developing an anxiety-related disorder. Which of the following clients is at greatest risk for developing an anxiety-related disorder? A client who has a family history of cancer and is recently unemployed. A client who had multiple adverse childhood experiences and whose parents both have a history of anxiety disorder. A client who did not graduate from high school or complete their general education development (GED) test. A client who has a family history of anxiety disorders and several positive childhood experiences (PCES).

A client who had multiple adverse childhood experiences and whose parents both have a history of anxiety disorder. This client's combination of genetic and environmental stress indicates that they are at greatest risk for the development of an anxiety disorder.

A nurse is reviewing data for a client who is manifesting symptoms related to a neurodevelopmental disorder. Which of the following tools should the nurse use to best screen the data for a neurodevelopmental disorder? Neurological assessment scale Medical history form Family composition questionnaire ADHD-FX

ADHD-FX The ADHD-FX is a helpful ADHD screening tool that uses a questionnaire to assess function in a variety of settings, such as academic, social, and at home.

A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client? Good vs. bad Justified vs. unjustified Adaptive vs. maladaptive Right vs. wrong

Adaptive vs. maladaptive Using the concept of "adaptive vs. maladaptive" allows the nurse to develop necessary context to both understand and deliver nursing care.

A nurse is caring for a client who has dementia and has been placed on the MIND diet plan. Which of the following foods should the nurse offer the client for a snack? Graham crackers Sliced apples Cheese crackers Almonds

Almonds The nurse should recommend almonds to the client for a snack. Almonds are high in omega-3 fatty acids, which can slow the progression of or delay the disease.

A nurse is participating in a hospital committee to discuss rationing of care and resources during a pandemic. The nurse should identify that which of the following behaviors is important in providing ethical and empathetic nursing care? Be honest, caring, and consistent Be transparent, honest, and credible Be transparent, collaborative, and consistent Be credible, collaborative, and consistent

Be transparent, collaborative, and consistent Being a nurse is a holistic role, and when rationing of resources is necessary, a nurse should be transparent, collaborative, and consistent in practice and care.

A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder? Sertraline Antihistamines Benzodiazepines Amphetamines

Benzodiazepines The nurse should identify that benzodiazepines can have an adverse effect of delirium. Benzodiazepines are central nervous system depressants used to treat insomnia, anxiety, and seizures.

A nurse is preparing to give a hand-off report regarding a client who has acute stress disorder following a suicide attempt. Which of the following symptom domains of trauma should the nurse include in the report? Cognitive, Psychological, Physical, Safety Safety, Physical, Social, Intellectual Psychological, Environmental, Physical, Behavioral Cognitive, Emotional, Behavioral and Physical

Cognitive, Emotional, Behavioral and Physical Nurses should assess a client's symptoms cues affecting the cognitive, behavioral, physiological, and emotional domains.

A nurse is assessing a 10-year-old child who has an autism spectrum disorder. Which of the following findings are expected? Difficulties in mastering the rules of spelling Continuous rocking of the body Difficulty reading instructions for a game. Difficulties in remembering facts and numbers

Continuous rocking of the body This is a repetitive behavior that is a hallmark characteristic of ASD.

A nurse is teaching a client who has an eating disorder about mindfulness and distress tolerance skills. This is an example of which of the following treatment modalities? Humanistic therapy Interpersonal therapy Dialectical behavior therapy Cognitive therapy

Dialectical behavior therapy Dialectical behavioral therapy involves providing validation about what the client is experiencing and feeling. This therapy promotes mindfulness and distress tolerance skills.

Which of the following is an example of inattentiveness seen in an adolescent who has ADHD? Difficulty waiting their turn Difficulty completing their homework Difficulty staying seated in class Listening attentively

Difficulty completing their homework Completing homework requires attention and mental effort.

A nurse is caring for a client who has an eating disorder. Which of the following actions should the nurse plan to take during the orientation phase of the nurse-client relationship? Identify areas that are causing problems in the client's life. Perform self-reflection activities. Provide education about the eating disorder. Discuss the timeline of the relationship.

Discuss the timeline of the relationship. The nurse should establish a contract about the timeline of the nurse-client relationship during the orientation phase.

A nurse is creating a presentation about suicide prevention. When providing information about the prevalence of suicide, the nurse should include that a death occurs how often in the United States? Every 11 min Every hour Every 2 hr Every 20 minutes

Every 11 min The nurse should identify that suicide is the tenth leading cause of death in the United States, accounting for one death every 11 min.

Which of the following characteristics would a nurse expect to find in an adolescent who has ADHD? Taking multiple attempts in completing verbal sentences Manifestations of an anxiety related disorder Expressing difficulties in reading assignments at school Manifestations of a schizophrenia spectrum related disorder

Expressing difficulties in reading assignments at school Difficulties in reading words is associated with dyslexia.

A nurse is educating a newly licensed nurse about comorbidities associated with cluster B personality disorders. The nurse should identify which of the following disorders as a comorbidity of histrionic personality disorder? Schizophrenia Anorexia nervosa General anxiety disorder Obsessive-compulsive disorder

General anxiety disorder The nurse should identify that generalized anxiety disorder is a comorbidity for cluster B personality disorder.

Which of the following comorbid conditions might a nurse expect to see in a client who has ADHD? Down syndrome Spinal stenosis Learning disabilities Schizophrenia

Learning disabilities Serious academic and learning deficits frequently occur in clients who have ADHD.

A nurse is setting goals for a client who has bulimia nervosa. Which of the following goals should the nurse identify as the priority? Establishing a therapeutic relationship Identifying the cause of the eating disorder Medical stabilization Interrupting the binge-purge cycle

Medical stabilization The nurse should identify that medical stabilization is the highest priority for a client who has bulimia nervosa.

A nurse is caring for a client who has a head injury. The client states they fell off a ladder while painting approximately 2 hr ago and lost consciousness for 45 min according to their partner. The nurse should determine that the client is experiencing which of the following classifications of traumatic brain injury? Severe No traumatic brain injury Moderate Mild

Moderate According to the severity rating scale for traumatic brain injury (TBI), the nurse should determine the client's injury is moderate because the client lost consciousness for longer than 30 min along with posttraumatic amnesia from 24 hr to 7 days and a Glasgow score of 9 to 12.

A nurse is caring for a client who presents to an outpatient treatment center seeking help for gambling. After performing an intake assessment, the nurse should identify which of the following statements by the client as a sign of a gambling addiction? "I can't sleep at night. I have insomnia." "I have had bipolar disorder for over 10 years." "My parents are my support system." "My wife left me. I lost my job and had to file for bankruptcy."

My wife left me. I lost my job and had to file for bankruptcy." The client's statement indicates that they have experienced loss of relationship, loss of career, and monetary losses such that they had to file for bankruptcy. These things are reflective of a gambling addiction.

A public health nurse is applying for a grant related to suicide prevention. When describing social groups at highest risk, which of the following should the nurse include? South American Native American African American Japanese American

Native American The highest rates of suicide are among Native American and non-Hispanic White Americans, veterans, people in rural areas, and people who work in certain industries like mining and construction.

A nurse is covering a phone triage line for trauma and crisis support. A client on the phone asks, "Can you help me understand how trauma-related disorders develop?" Which of the following responses by should the nurse provide? "Developing a trauma-related disorder is the result of a chemical imbalance in the brain." "Developing a trauma-related disorder is the result of genetics; people are born that way." "Developing a traumatic disorder requires an experience of physical harm. " "Experiencing or witnessing a traumatic event can result in developing a trauma-related disorder."

"Experiencing or witnessing a traumatic event can result in developing a trauma-related disorder." This should be included in the nurse's response. Experiencing or witnessing trauma at any time during one's life can result in developing a trauma-related disorder. It is also important to understand that not all people who experience trauma will develop a trauma-related disorder.

A nurse is caring for a client who has returned from a bereavement support group. Which of the following client statements demonstrates that the client is meeting the planned outcomes of treatment? "No matter how much I try, I can't forget the night they died. I wonder if I ever will?" "People never really understand what my partner's death means to me. I really miss them." "I will take the kids to the ocean. We had great times there as a family, and it's time for more memories." "Our time together was so short. I just wish I had shown them how much I appreciated them."

"I will take the kids to the ocean. We had great times there as a family, and it's time for more memories." Accepting the death of the loved one and the loss is evidence that bereavement care and therapy are working.

A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation? "Walking around the hospital grounds has been helping me." "I'm going to give my sister my pottery collection when I get home." "I'm going to continue to not drink alcohol when I get home." "I'm looking forward to seeing my grandchildren when I get out of here."

"I'm going to give my sister my pottery collection when I get home." The nurse should identify that clients who are considering self-harm often give away their favorite personal belongings.

A nurse is caring for a client who states, "My mother and my mother's mother have all been in abusive relationships. We know this is because of what happened to our people 100 years ago with slavery." Which of the following responses by the nurse expresses understanding of the client's trauma? "It appears that you are explaining historical trauma. Can you tell me more?" "Did this trauma happen when you were a young child?" "I am sorry about the trauma you and your family experienced." "It must be difficult to be in an abusive relationship."

"It appears that you are explaining historical trauma. Can you tell me more?" This client has identified how historical trauma can affect current experiences of trauma. Asking the client to explain more allows them to discuss their personal experiences and acknowledges what has happened to their family and people group.

A nurse is caring for a client who has a prescription for a bone densitometry test. The nurse should identify that this test is used to assess for which of the following conditions? Osteopenia Hyperphosphatemia Hypocalcemia Bone fractures

Osteopenia A bone densitometry test is used to detect osteopenia/osteoporosis, which is a potential complication of anorexia nervosa.

A nurse is caring for a client who has dementia and has a prescription for levodopa. Which of the following types of dementia should the nurse identify that the client has? Vascular disease HIV infection Parkinson's disease Prion disease

Parkinson's disease The nurse should identify the client has Parkinson's disease dementia. Levodopa is a medication used to treat this type of dementia.

A nurse is caring for a client who has borderline personality disorder. Which of the following defense mechanisms is commonly used by clients who have this disorder and has the potential to create division amongst the healthcare team? Regression Reaction formation Denial Splitting

Splitting Splitting is a behavior that involves describing people as all good or all bad and is a manipulative behavior to get the client's own way. If the collaborative team tolerated this behavior, it could cause friction amongst the treatment team.

A nurse is caring for a client who was recently diagnosed with an opioid use disorder. They were a student in a local community college but were recently dismissed for failing their classes. Their previous diagnoses include anxiety, Crohn's disease, and chronic back pain due to a gymnastics injury in high school. Which of the following should the nurse identify as potential underlying reasons why the client might have started using opioids? To promote sleep and rest To treat hallucinations and perform better at work To treat pain and ease anxiety Because they witnessed their parents using drugs or alcohol to cope

To treat pain and ease anxiety Pain relief and anxiety reduction are two of the reasons that people might take drugs and alcohol.

A nurse is caring for a client who has post-traumatic stress disorder and is considering prolonged exposure therapy. The client asks, "How does this therapy work?" Which of the following responses by the nurse accurately describes this type of therapy? "A therapist simulates your eye movement while you focus on your traumatic experience to reduce the connection of your memories to the trauma." "A therapist helps you safely and gradually face memories or situations related to your trauma that evoke fear." "A therapist encourages you to talk as a way developing self-awareness; this can help you change old behaviors by taking charge of your life. " "A therapist teaches you to understand the connection between what you think and feel, and how it affects your behavior. "

"A therapist helps you safely and gradually face memories or situations related to your trauma that evoke fear." This is an accurate description of prolonged exposure therapy, which is a form of cognitive behavioral therapy that includes exposure to situations, people, or objects that the patient is avoiding.

A nurse is assessing a newly admitted client who has bulimia nervosa. Which of the following client statements should the nurse expect? "I feel energized when I binge and purge." "I feel preoccupied about my body shape." "I feel confident in my abilities." "I feel in control of my life."

"I feel preoccupied about my body shape." Eating disorders involve intense preoccupation with weight and body image.

A nurse is caring for a client who has a binge-eating disorder. Which of the following statements should the nurse expect from this client? "My binges usually start off with feeling hungry." "I binge to reward myself for completing difficult tasks." "I feel so defeated and want to hide after I have binged." "I am able to control the pace of my bingeing when I start getting full."

"I feel so defeated and want to hide after I have binged." Binges are associated with emotional distress, including shame, disgust, and embarrassment.

A nurse is observing a group therapy session. Which of the following client statements should the nurse identify as an indication of bulimia nervosa? "I feel an emotional high during my binge-purge episodes." "I only use the laxatives when I am feeling constipated." "I feel a sense of power by restricting my food intake." "I have binged and purged for years without my family or friends knowing."

"I have binged and purged for years without my family or friends knowing." Clients who have bulimia nervosa typically hide bingeing and purging behaviors from others.

A nurse is admitting a client who has anorexia nervosa. Which of the following statements should the nurse expect from this client? "I restrict myself to 2,000 calories per day." "I have certain foods, like pizza, that cause me a lot of fear." "I don't eat because I do not like the taste of food." "I don't bother to track the number of calories I eat in a week."

"I have certain foods, like pizza, that cause me a lot of fear." CORRECT Clients who have anorexia nervosa often have "fear foods" that produce feelings of anxiety.

A nurse has completed an assessment of a client whose parent recently died. Which of the following client statements is an indication that the client is experiencing death anxiety? "I have had trouble sleeping. I wake up and go to my parent's room to find them." "I just don't understand why this happened. My thoughts have been so mixed-up since they died." "I just can't stop thinking about my own death. Life is so short." "I am so sad. It is very hard to consider what holidays will be like."

"I just can't stop thinking about my own death. Life is so short." Death anxiety is an emotional response and feeling of insecurity and anxiety a person can experience when considering death or dying.

A nurse is discussing medication used for maintaining alcohol abstinence with a client who is undergoing this type of treatment. Which of the following statements by the client indicates an understanding of their prescriptions? "I know I will be taking naltrexone in accordance with my provider's instructions to help me avoid using alcohol." "I know I need to take benzos several times a day to keep from drinking alcohol." "I understand that my medication will help me cut down to 2 drinks a day." "I know that when taking disulfiram that I can only have 3 alcohol drinks a day."

"I know I will be taking naltrexone in accordance with my provider's instructions to help me avoid using alcohol." This answer correctly identifies that alcohol abstinence maintenance is treated with naltrexone and acamprosate.

A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. Which of the following client statements indicates that the client is experiencing traumatic grief? "I can't cry when I talk about my friend because soldiers aren't supposed to show emotions." "It has been more than a year, and I still don't want to leave the house." "I should have been the one who had been killed instead of my friend." "When I have flashbacks, it feels like my heart is going to beat through my chest."

"I should have been the one who had been killed instead of my friend." This statement indicates self-blame or guilt, which is a manifestation of traumatic grief. A client's response is often intensified by disbelief or shock, feelings of anger or numbness, self-blame or guilt, a sense of fear or danger, loss of meaning.

A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa? "I spend lots of time searching for new recipes." "I know I am skinny." "I enjoy wearing form-fitting clothes to show off my body." "I have so much energy."

"I spend lots of time searching for new recipes." Clients who have anorexia nervosa typically demonstrate a high interest in preparing food, but not in eating.

A nurse is providing care to a client who has acute stress disorder. Which of the following client statements is consistent with this disorder? "My parents fought a lot when I was a child. Now, when I hear people yelling or fighting, I feel like I left my body." "I was physically abused when I was a child and have frequent flashbacks since then." "I was in a car crash 2 weeks ago and I have nightmares when I sleep." "I was in a terrible car crash 2 years ago and I have been unable to drive a car since then."

"I was in a car crash 2 weeks ago and I have nightmares when I sleep." This client's symptoms are consistent with acute stress disorder, which lasts between 3 days and 1 month after the traumatic event. If symptoms last beyond 1 month, then a mental health provider may consider a diagnosis of posttraumatic stress disorder.

A nurse is providing teaching about eating disorders to a group of clients. Which of the following client statements indicates an understanding of the teaching? "There are very few people affected by eating disorders." "Since I have only had my eating disorder for a year, it is not that serious." "I will need to ask for professional help if I want to recover from my eating disorder." "I can overcome my eating disorder if I just start eating."

"I will need to ask for professional help if I want to recover from my eating disorder." Due to the complexity and seriousness of eating disorders, client's should seek professional help to support the recovery process. Therefore, this statement indicates an understanding of the teaching.

A nurse in an outpatient facility is teaching a client about the development of mental illness. Which of the following statements by the nurse describes the role of a vulnerability gene? "It is a gene variant that increases the risk for development of a specific mental illness." "It is a gene variant that is responsible for an individual's resilience to stress." "It is a gene variant that determines an individual's likelihood of recovering from mental illness." "It is a gene variant that is responsible for the development of a specific mental illness."

"It is a gene variant that increases the risk for development of a specific mental illness." Research over the past decade has illuminated several vulnerability genes that appear to be associated with an increased risk for developing mental illness.

A nurse working in a detoxification unit is reviewing the process of addiction. The nurse should identify that which of the following parts of the brain are implicated in the reward pathway leading to addiction? Prefrontal cortex, brain stem, and frontal cortex Cerebellum, pons, and medulla oblongata Basal ganglia, extended amygdala, and prefrontal cortex Midbrain, cerebrum, and temporal lobe

Basal ganglia, extended amygdala, and prefrontal cortex CORRECT The basal ganglia, extended amygdala, and prefrontal cortex are the areas of the brain identified in the addiction process.

A teenage client who has autism spectrum disorder (ASD) tells a nurse, "I'm not doing well in all my classes. I am not learning as fast as everyone else." Which of the following actions should the nurse take? Recommend that the client consult with a psychologist. Refer the client to a neurodevelopmental specialist. Suggest the client undergo a neurological assessment. Coordinate a meeting with the client and school counselor.

Coordinate a meeting with the client and school counselor. A nurse can act as an advocate for a client in coordinating care, education, and skill development with teachers and school staff to promote good outcomes.

A nurse is caring for a client who has Alzheimer's disease and is having difficulty with multitasking. Which of the following cognitive deficits is the client experiencing? Perceptual-motor Learning and memory Executive function Complex attention

Executive function The nurse should identify a client who has Alzheimer's disease and is having difficulty with multitasking is experiencing a cognitive deficit of executive function. Executive function includes planning, decision making, mental flexibility, and a working memory.

A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide? Loss of a job Engaging in extracurricular activities Financial stability Exercising caution in behavior

Loss of a job CORRECT The nurse should identify that a risk factor for suicide is the loss of a job and therefore should be included in the presentation.

A nurse is caring for a client who has binge-eating disorder. Which of the following actions should the nurse plan to take during the termination phase of the nurse-client relationship? Review treatment goals that have been accomplished. Gather data about the client's home situation. Provide personal contact information to the client for use in case of emergency. Introduce the concept of discharge planning.

Review treatment goals that have been accomplished. The nurse should plan to review treatment goals that have been accomplished during the termination phase of the nurse-client relationship

A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal? The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal. Stage 2 (moderate) Stage 1 (mild) Stage 3 (severe)

Stage 3 (severe) Stage 3 withdrawal includes disorientation, hallucinations, and seizures.

A nurse is reviewing a client's MRI results that show cortical thinning. The nurse should identify that this finding is evident in which of the following types of dementia? Prion disease Alzheimer's disease Substance use disorder HIV infection

Substance use disorder The nurse should identify that cortical thinning is associated with a client who has substance use disorder dementia.

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm? When getting married When attending narrative therapy When discharged from the hospital When attending dialectical behavior therapy

When discharged from the hospital The nurse should identify that discharge might cause clients who have borderline personality disorder to feel rejected and be a trigger for high emotionality, which can lead to self-harming behaviors.

Which of the following questions should a nurse ask when assessing a pediatric client's risk factors for autism spectrum disorder (ASD)? "Are the parents younger than 25 years of age?" "Does the child have a twin who has similar manifestations?" "Does the child have gastrointestinal (GI) disorders?" "Has the child received all their vaccinations?"

"Does the child have a twin who has similar manifestations?" If one twin has ASD, the other is likely to be affected 36% to 95% of the time.

A nurse is providing education to a group of clients about the health effects of eating disorders. Which of the following client statements indicates an understanding of the teaching? "Anorexia can cause hypertension." "Eating disorders do not affect the kidneys." "Eating disorders can prevent the onset of the menstrual cycle." "Bulimia has no long-term health effects."

"Eating disorders can prevent the onset of the menstrual cycle." Some clients diagnosed with an early age onset of anorexia nervosa have never had their menstrual cycle due to their percentage of low body fat and hormonal deficiencies.

A nurse is screening a young adult for an eating disorder using the SCOFF questionnaire. Which of the following questions by the nurse represents the "O" for this assessment tool? "Have you experienced trouble with overeating?" "Do you think of yourself as overweight, even when others say you are thin?" "Have you recently lost more than 14 pounds in a 3-month period?" "Do you feel like you are outgoing?"

"Have you recently lost more than 14 pounds in a 3-month period?" The "O" of the SCOFF questionnaire represents "one stone," which is a British unit of measurement equivalent to 6.35 kg (14 lb). Therefore, this question represents the "O" for this assessment tool.

A nurse is caring for a client who has recently experienced a mental health crisis which resulted in the client being physically restrained. Which of the following statements by the client indicates the client is indicate that the crisis has passed? "This is a joke. You are all a joke. I just got to get out of here now." "I just need to sleep. If you could just give me something to help me sleep, I would be okay." "I cannot face my family. But I don't think I can get up and walk around." "I am feeling calmer and am hungry. I think I'm ready to talk about what happened."

"I am feeling calmer and am hungry. I think I'm ready to talk about what happened." This client statement indicates that they have become calm and are willing to reflect on the situation. This client is demonstrating being at a functional level which is safe and that the mental health crisis has passed. Recognition of being hungry and feeling calmer as well as willing to talk about what happened reflect return to a stable level of functioning.

A nurse at a primary care clinic is assessing a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression? "When I went to my provider, they told me I have high blood pressure." "Lately, I feel like I am more alert than usual and can focus better." "I can't sit still. I feel like I need to be doing things around the house." "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours."

"I can't get my mind to stop racing at night. I'm only sleeping a couple of hours." The nurse should identify that insomnia and hypersomnia can both be findings of depression.

A nurse is caring for child who was resuscitated after drowning, is intubated, and has met the legal criteria of death. The health care team and parents have decided to stop all treatment and extubate. Which of the following statements by the nurse reflects that they are experiencing moral distress? "I could never give up on my child. I feel sick to my stomach." "The child is only 4-years-old. They can't give up now." "I can't believe that the parents were so negligent and didn't have a fence around the pool." "My faith would never let me make this decision for my child." "I am just so angry. This is a beautiful child with so much living ahead of them."

"I could never give up on my child. I feel sick to my stomach" is correct. This is an expression of personal values. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse ."The child is only 4-years-old. They can't give up now" is correct. This is an expression of anger and frustration, which are manifestations of moral distress. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse. "My faith would never let me make this decision for my child" is correct. This is an expression of personal beliefs and values. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse ."I am just so angry. This is a beautiful child with so much living ahead of them" is correct. This is an expression of anger and shock, which are manifestations of moral distress. Moral distress occurs when treatment choices for a client are inconsistent with the personal or moral values of the nurse.

A nurse is caring for a client who is recovering from a femur fracture sustained in a motor-vehicle crash. Their partner died in the collision. Which of the following client statements would indicate that the client is experiencing avoidance symptoms? "I just cannot remember anything about the accident." "I don't want to think or talk about what happened with anyone." "I am just so sad. I cannot believe that my partner is gone." "If I wasn't such a bad person, this never would have happened."

"I don't want to think or talk about what happened with anyone." CORRECT This is an example of an avoidance symptom. A client experiencing avoidance symptoms will make an effort to avoid memories, conversations, thoughts, and feelings about their traumatic experience. They may also avoid people, places, or objects that remind them of their trauma.

A nurse is performing an initial assessment of a client who has anorexia nervosa. Which of the following client statements should the nurse expect? "I like the way I look." "I hope I will be able to gain weight during my stay." "I feel hungry most of the day." "I feel fat."

"I feel fat." Clients who have anorexia nervosa have a distorted body image and often perceive themselves as overweight, even if they are severely underweight.

A nurse is caring for a client who reports frequent social use of alcohol. The client tells the nurse that they have been reprimanded at work for being late several times after they had been out late drinking. Which of the following statements by the client might indicate that the client has developed a substance use disorder? "I am so focused right now. I have a lot of goals." "I have lost 15 pounds! I just don't want to eat lately." "I am taking art lessons to relieve stress." "I have been hanging out with friends who are my support system."

"I have lost 15 pounds! I just don't want to eat lately." Changes in weight and eating habits may be warning signs of a substance use disorder.

A nurse is proving care for a client. Which of the following client statements suggests receptive language disorder? "I have trouble following instructions because I don't understand what people are telling me." "People accuse me of being happy when something bad happens because I often smile." "People don't understand me because I can't find the right words to say." "I have trouble understanding people because my mind wanders while they are talking."

"I have trouble following instructions because I don't understand what people are telling me." This statement would suggest the individual has a hard time comprehending what others say and has a difficult time applying information and following instructions.

A nurse is teaching a group of students about the prevalence of eating disorders in the U.S. Which of the following statements by a student indicates an understanding of the teaching? "It is estimated that 10 million people in the United States have an eating disorder." "The prevalence of eating disorders in the United States is lower compared to other countries." "It is difficult to determine the prevalence of eating disorders due to the secretive nature of these conditions." "Eating disorders are over diagnosed due to dieting fads."

"It is difficult to determine the prevalence of eating disorders due to the secretive nature of these conditions." The prevalence of eating disorders is difficult to determine due to the secretiveness of these conditions. Many clients who are experiencing an eating disorder will deny that the condition exists and avoid seeking help.

A nurse on a mental health unit is caring for a client who has a new diagnosis of borderline personality disorder. The client states "I will just see my regular doctor at my annual checkup after I am discharged." Which of the following responses should the nurse make? "You have made such great progress here. I can see why you feel so well." "Since you have such a good relationship with your family practice provider, you do not need to see a mental health provider." "You should follow up with your regular doctor in the next few months so they can manage your new diagnosis." "It is recommended that you receive follow-up care from a mental health provider after you are discharged.

"It is recommended that you receive follow-up care from a mental health provider after you are discharged." The nurse should identify that clients who have personality disorders will need to be followed by mental health specialists for a period of time after hospitalization.

A nurse manager is evaluating staff to determine if efforts to reduce occupational stress have been successful. Which of the following statements by a staff member indicates that the occupational stress on the unit has been decreased? term-119 "Lately, we have had many client deaths. Now, we will take a break or even a pause after the death." "We are constantly asking for help, some clients are readmitted every week, and nothing changes." "Work is nonstop: no breaks or lunch." "People call in sick, so most days you just have to put your head down and work on your own."

"Lately, we have had many client deaths. Now, we will take a break or even a pause after the death." This statement recognizes a cause of occupational stress, multiple client deaths, and provides an example of a strategy, taking a break, that allows the nurses to consider their own thoughts and feelings.

A nurse is caring for a client who has a substance use disorder. Which of the following statements by the nurse is an example of patient-centered care? "Although you have mentioned wanting to talk today about your past abuse, let's discuss this handout I have with new coping skills." "Let's review the goals you set today and see what your priority is this week." "I would like to focus on what I believe are the best goals for you to work on." "I am going to have to change our meeting time because I need to go get lunch."

"Let's review the goals you set today and see what your priority is this week." The nurse should provide patient-centered care by asking them what their most important goal is at each visit is will show the client they are the focus.

A nurse is caring for an adolescent who has an anxiety disorder. Which of the following statements by the adolescent indicates a protective factor in the form of a positive childhood experience? "My English teacher is amazing. They really listen well." "My parents are in the military. We have moved a lot since I was born." "My mother had me when she was in high school." "My little sister has a lot of health problems, and my parents are always in the hospital with her. I worry about that a lot."

"My English teacher is amazing. They really listen well." Having caring adults outside the family who serve as mentors and role models is an example of a positive childhood experience. Therefore, this statement by the adolescent indicates a protective factor in the form of a positive childhood experience.

A nurse is presenting information about the epidemiological aspects of eating disorders at a community health fair. Which of the following statements from a participant indicates a need for further teaching? "Eating disorders have one of the highest death rates among mental health disorders." "Around 30 million Americans have experienced an eating disorder." "Someone dies due to an eating disorder every 15 minutes." "Less than half of people with eating disorders seek help for their condition."

"Someone dies due to an eating disorder every 15 minutes." This statement is inaccurate and indicates a need for further teaching. The nurse should reinforce that someone dies due to an eating disorder every 52

A nurse is meeting with a 15-year-old client who has ADHD The client and their parent state they would like their medications stopped due to the unpleasant side effects. Which of the following statements should the nurse make? "It is important to take the medication as prescribed." "I will go get the physician to discuss this situation." "Tell me more about what unpleasant effects you have been experiencing." "Stop taking the medication immediately."

"Tell me more about what unpleasant effects you have been experiencing." The nurse's role is to advocate for the best interest of the client. The nurse would further assess what adverse effects the client is experiencing. Advocacy also includes talking to the provider about changing the dose of medication or switching to a different medication to decrease negative effects.

A nurse is teaching a newly licensed nurse about eating disorders. Which of the following statements should the nurse include in the teaching? "There are many different types of eating disorders." "Eating disorders have a low mortality rate compared to other mental illnesses." "Eating disorders are primarily caused by a lack of information about nutrition." "Eating disorders only affect females."

"There are many different types of eating disorders." There are a variety of eating disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, among others

A nurse is conducting a psychoeducation group about the etiology of eating disorders. Which of the following statements should the nurse include? "Childhood trauma is the primary contributor to the development of an eating disorder." "There is a mix of biological and psychosocial determinants that contribute to the development of eating disorders." "A specific gene has been identified as the primary cause of eating disorders." "Western cultural values are the primary cause of eating disorders."

"There is a mix of biological and psychosocial determinants that contribute to the development of eating disorders." The cause of an eating disorder is multifactorial and best explained by the diathesis-stress model, which poses that there are environmental and psychosocial factors, as well as biological and genetic factors that contribute to the development of an eating disorder.

A nurse is preparing a client for electroconvulsive therapy (ECT). Which of the following client statements indicates an understanding of the procedure? "This procedure will cause me to have brief seizures." "I will be able to eat breakfast prior to my procedure." "I will not need to have a pre-ECT workup before the procedure." "One ECT treatment will be effective for my depression."

"This procedure will cause me to have brief seizures." While an electrocardiograph (ECG) and electroencephalograph (EEG) monitor the client, brief seizures are induced by electrical current attached to one or both sides of the forehead.

A nurse is educating a parent of an infant that has failed to reach specific developmental milestones. Which statement should the nurse include? "Usually a diagnosis of global developmental delay can be made when a child does not meet milestones. Then, when the child is older, more testing can be done." "When an infant fails to meet certain important milestones, an intellectual disability can be diagnosed by a pediatrician." "A diagnosis of any type of neurodevelopmental disorder cannot be provided until a child is old enough to take a critical thinking test." "Unless trauma or injury is suspected, a child should be monitored for neurodevelopmental progress for a few years before a diagnosis is made."

"Usually a diagnosis of global developmental delay can be made when a child does not meet milestones. Then, when the child is older, more testing can be done." Standardized developmental screenings at various intervals of well-child visits or whenever a parent or clinician expresses a concern, as well as autism-specific screening at 18 and 24 months of age and at any subsequent visits.

A guardian is concerned that their child, who has autism spectrum disorder (ASD), is having difficulty at school despite being in a specialized learning environment. Which of the following statements should the nurse make? "Many children with ASD have to work harder at school, but your child can succeed with enough effort." "Your child may have a coexisting condition that is affecting school performance, so we can arrange an additional evaluation to determine the best actions." "I can speak to the pediatrician about increasing your child's medication, and this will likely help with school performance." "Your child may have an intellectual disorder, instead of ASD, that is causing difficulty with school work, so a different educational program may be needed."

"Your child may have a coexisting condition that is affecting school performance, so we can arrange an additional evaluation to determine the best actions." It is common for neurodevelopmental disorders to coexist with other conditions, so further evaluation should be done to identify the appropriate combinations of interventions that will provide the best outcomes.

A nurse is providing an in-service to a group of nurses on medications used to treat the progression of Alzheimer's disease. Which of the following medications should the nurse include in the teaching? Levodopa Tetrabenazine Aducanumab Warfarin

Aducanumab The nurse should identify that aducanumab, an amyloid beta-directed antibody, is used to treat the progression of Alzheimer's disease.

A nurse has successfully completed a drug treatment program and is returning to work 3 months later. Which of the following best describes a program designed for a nurse returning to work after treatment? An Alternative-to-Discipline (ATD) program A drug recovery support group An early-release incarceration program An involuntary long-term residential treatment program

An Alternative-to-Discipline (ATD) program An alternative-to-discipline (ATD) program is one in which the nurse who has had a substance use disorder will not practice nursing for a designated time while being involved in a recovery program or undergoing treatment.

A nurse is meeting with a new client at a substance use disorder clinic. During which of the following step of the nursing process should the nurse identify the types of interventions that might produce the best client outcomes? Evaluation Planning Analysis/diagnosis Implementation

Analysis/diagnosis This accurately describes analysis. Based on the patient's assessment, the nurse will determine the client's problems, which will help the team of health care professionals involved in the client's care to make decisions about treatment.

A nurse on a mental health unit is caring for a client who refuses to follow instructions and states that the unit rules do not apply to them. The nurse should identify that these findings are manifestations of which of the following personality disorders? Antisocial personality disorder Schizotypal personality disorder Histrionic personality disorder Narcissistic personality disorder

Antisocial personality disorder The nurse should identify that antisocial personality disorder is characterized by repeated violation of laws and rules, as clients with this disorder often believe that rules do not apply to them.

A nurse is planning care for a client who has been brought to the inpatient mental health unit by law enforcement officers after becoming aggressive in a local bar. The nurse should identify that this finding is consistent with which of the following disorders? Borderline personality disorder Narcissistic personality disorder Histrionic personality disorder Antisocial personality disorder

Antisocial personality disorder The nurse should identify that antisocial personality disorder is characterized by aggression, disrespect for others, and getting in trouble with the law.

A nurse is caring for a client who has generalized anxiety disorder. The nurse should identify that which of the following statements describes anxiety as transdiagnostic in nature? Anxiety cannot manifest alongside other medical and psychiatric conditions. Anxiety can manifest alongside other medical and psychiatric conditions. Anxiety can only manifest in the presence of recognized nonmodifiable risk factors. Anxiety can only manifest in the presence of recognized modifiable risk factors.

Anxiety can manifest alongside other medical and psychiatric conditions. Anxiety is a transdiagnostic phenomenon that can coexist alongside varied psychiatric and medical conditions.

Which of the following is a behavioral sign of a learning disability in a child? Avoiding homework Slow work pace Excessive focus on details Lack of attention to details

Avoiding homework This is a behavioral sign that may be indicative of a learning disability.

A nurse is teaching the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority? Resources for group therapy in the community Medication compliance Awareness of potential for self-harm Information about insurance coverage

Awareness of potential for self-harm Clients with borderline personality disorder are at risk for self-harm, so caregivers should be taught safety precautions as the highest priority.

A nurse is providing an in-service about the prevalence of eating disorders. Which of the following information should the nurse include? The prevalence of eating disorders is decreasing. Anorexia nervosa is the most prevalent type of eating disorder. Binge-eating disorder is the most prevalent type of eating disorder. Bulimia nervosa is the most prevalent type of eating disorder.

Binge-eating disorder is the most prevalent type of eating disorder. Binge-eating disorder is the most prevalent type of eating disorder.

A nurse is leading a group about relapse prevention. Which of the following statements appropriately describes the principles of the self-help groups Alcoholics Anonymous and Narcotics Anonymous? Clients should believe in their own ability to beat the disease by themselves. Clients are powerless over addiction, and it can only be overcome through belief in a higher power. Clients turn over control and responsibility to another person who can help them abstain from substances. Substance use disorders are pre-destined in individuals and cannot be overcome, only controlled.

Clients are powerless over addiction, and it can only be overcome through belief in a higher power. These programs have a core belief in a higher power, as defined by each individual group member.

A nurse is caring for a client who has an eating disorder. The nurse should identify that eating disorders are challenging to treat due to which of the following factors? The treatment of an eating disorder depends primarily on psychotropic medication. Clients who have an eating disorder struggle with eating, which is necessary to live. Clients who have an eating disorder must be treated on an inpatient basis. Eating disorders have an abrupt onset.

Clients who have an eating disorder struggle with eating, which is necessary to live. The nurse should identify that eating disorders are challenging to treat because they involve a disruption in eating, which is necessary to live.

A nurse is meeting with a client and their family at a local treatment clinic. The client's partner demands to see the client's records and treatment plan, and states they need to be responsible for overseeing the treatment. The client's partner reports that their own health has deteriorated since caring for the client. The nurse should recognize that the client's partner is displaying which of the following behaviors? Codependency Marginalization Manipulation Enabling

Codependency The question accurately describes codependency.

Which of the following statements indicates a positive outcome for a client who has a stereotypical motor disorder? Calculates basic math problems Controls impulsive movements when excited Engages in conversation with peers Exhibits considerate behavior with family members

Controls impulsive movements when excited A client with a stereotypical motor disorder would have difficulty controlling impulsive movements when excited, so a good outcome statement to evaluate progress of interventions would be to control these movements effectively.

A client is experiencing complicated grief and has been diagnosed with prolonged grief disorder (PGD). Which of the following should the nurse include in the plan of care for a client who has PGD? Create a safe, confidential environment. Encourage the client to talk about their loss. Provide education regarding specialized treatment such as complicated grief therapy. Ask the client why their grief manifestations continue.

Create a safe, confidential environment is correct. Creating a safe and confidential environment is essential for client healing and positive client outcomes. Encourage the client to talk about their loss is correct. Encouraging a client to talk about their loss is essential for developing a trusting therapeutic relationship and an aspect of a grief-informed approach .Provide education regarding specialized treatment such as complicated grief therapy is correct. Client plan of care for PGD includes specialized treatment and education regarding specialized therapies should be include in a client's plan of care.

A nurse is caring for a female client who has bulimia nervosa and reports frequent self-induced vomiting. Which of the following findings should the nurse expect? Lower than normal expected reference range of body weight Hyperkalemia Amenorrhea Dental decay

Dental decay The nurse should expect dental decay for a client who reports frequent self-induced vomiting because this causes tooth enamel to become eroded, causing dental decay.

A nurse is discussing the three clusters of personality disorders. Which of the following personality disorders is part of cluster C? Antisocial personality disorder Borderline personality disorder Paranoid personality disorder Dependent personality disorder

Dependent personality disorder Dependent personality disorder is in cluster C, along with avoidant personality disorder and obsessive-compulsive personality disorder.

A nurse is caring for a client who is unable to make any decisions for themself and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders? Antisocial personality disorder Schizoid personality disorder Dependent personality disorder Avoidant personality disorder

Dependent personality disorder The nurse should identify that clients who have dependent personality disorder lack confidence and often feel unable to care for themselves.

A nurse is caring for a client who has a history of angina. Nurses' Notes 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. 1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations. Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid. Vital Signs 1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air 1200: Temperature 37.5° C (99.5° F BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 95% on room air A nurse is caring for a client who has type 1 diabetes mellitus and recently experienced significant weight loss. The client states, "I have been skipping my insulin to help lose weight." The nurse should identify that this is an indication of which of the following conditions? Diabulimia Bulimia nervosa Avoidant restrictive food intake disorder (ARFID) Anorexia nervosa

Diabulimia Diabulimia is an eating disorder that involves someone who has type 1 diabetes mellitus reducing or ceasing insulin treatment to lose weight.

A school nurse is planning a presentation about identifying potential warning signs of suicide for high school students. Which of the following examples of behaviors should the nurse include in the teaching? Seeking a tutor for help with a challenging class Volunteering to serve food at a homeless shelter over the holidays. Making plans to go to a high school dance Displaying extreme mood swings

Displaying extreme mood swings The nurse should include in the presentation that sudden and extreme mood swings might be a warning sign that a student is considering suicide.

A nurse is speaking with the caregiver of a client who has dementia and is experiencing anosmia. Which of the following information should the nurse provide about strategies for managing the client's anosmia? Encourage the client to receive more rest. Suggest flashcards to help the client recognize words. Dispose of food at the expiration date. Provide an activity for the client.

Dispose of food at the expiration date. The nurse should inform the caregiver to dispose of food at the expiration date due to the client's inability to smell.

A nurse works in which of the following roles when providing care to a client who has a tic disorder? Educating client and caregivers Prescribing behavioral therapy Diagnosing neurological conditions Prescribing pharmacological interventions

Educating client and caregivers The nurse can help clients and caregivers be aware of the elements of tic disorders and the options for addressing the condition.

A nurse is caring for a client who is exhibiting symptoms of emotional and physical trauma. Which of the following nursing actions is a priority when providing trauma-informed care for this client? Contact a social worker to report abuse. Ensure that the client is safe. Assess the client for social and family support. Encourage the client to talk about the experience.

Ensure that the client is safe. Ensuring client safety is the priority nursing action. Confirming that the client is physically and psychologically safe is the beginning point of healing.

A nurse is monitoring a client who has ADHD. The client is demonstrating disruptive behavior due to overstimulation from being in a group setting. Which of the following actions should the nurse take? Ask the client to express how they feel to the group. Initiate physical restraints. Administer an SSRI medication. Escort the client to a quiet room.

Escort the client to a quiet room. A quiet, unlocked room with soft objects can provide a safe, unrestrained place for a client to escape from overstimulation.

A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye's General Adaptation Syndrome (GAS) explains the possible cause for the adolescent's manifestations? Alarm Phase Adaptive Phase Exhaustion Phase Resistance Phase

Exhaustion Phase The exhaustion phase explains the possible cause for the adolescent's manifestations. In the exhaustion phase, the body finds itself depleted of energy reserves and is unable to self-regulate independently and reliably.

A nurse is caring for a client who is concerned about developing a mental health disorder as a result of their childhood experiences. Which of the following familial characteristics is a protective factor for adverse childhood experiences? Families where caregivers have college degrees or higher Families that include young caregivers or single parents Children who don't feel close to their guardians and don't feel like they can talk to them about their feelings Families that are isolated from other people, such extended family, friends, and neighbors

Families where caregivers have college degrees or higher Statistics show that caregiver characteristics such as having a college degree or having strong social supports is associated as a protective factor for adverse childhood experiences.

A nurse is teaching a parent about communicating with their teenage child who has anorexia nervosa. This is an example of which of the following types of therapy? Behavioral therapy Cognitive behavioral therapy Family-based therapy Humanistic therapy

Family-based therapy Family-based therapy involves providing a framework for family and friends to communicate with a client about their condition in a way that does not trigger the client, while also not enabling them. This is a first-line treatment for adolescents who reside with their parents.

A nurse is caring for a client who has bulimia nervosa has a new prescription for a selective serotonin reuptake inhibitor (SSRI). Which of the following medications should the nurse anticipate administering? Fluoxetine Valproate Naltrexone Olanzapine

Fluoxetine The nurse should identify that fluoxetine is an SSRI that is FDA approved for the treatment of bulimia nervosa.

A nurse is planning for a therapy dog to visit a client who has dementia. Which of the following is the purpose for this activity? Evoke the client's memories Decrease the client's depression Improve the client's cognitive function Relax the client

Freeze response The client is experiencing a freeze response. This can happen when the client becomes overwhelmed by the memory of the traumatic event, which causes the thinking centers of the brain to shut down, and the client may be unable to process new information. A freeze response is evident in how the client avoids the nurse's question about their symptoms.

A charge nurse is concerned by a nurse's recent behaviors. Which of the following behaviors by the nurse indicates that they are is experiencing burnout? Does not report known medication error Takes regular lunch breaks Frequently calls in sick Sets firm professional boundaries with clients

Frequently calls in sick Frequently calling in sick might be an expression of burnout or compassion fatigue, which is emotional exhaustion and a decreased ability to provide compassionate or empathic care.

A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following? Panic disorder Agoraphobia Separation anxiety disorder Generalized anxiety disorder

Generalized anxiety disorder The nurse should identify that these manifestations indicate generalized anxiety disorder. Generalized anxiety disorder involves experiencing excessive anxiety and worry in response to situations and circumstances, and the inability to control the sense of worry.

A nurse is caring for a client who has dementia. The provider has prescribed a protease inhibitor medication for the client. The nurse should identify that this medication is given to treat which of the following types of dementia? HIV infection Vascular disease Parkinson's disease Lewy body disease

HIV infection The nurse should identify that clients who have HIV infection dementia can be prescribed protease inhibitors, antivirals, and non-nucleoside revise transcriptase inhibitors for treatment.

A nurse is caring for a client who has been brought into an emergency department of a large hospital. The client's family state that the client "took some kind of drugs." The client is dizzy, has recently vomited, and is experiencing paranoia, yelling, "Stay away from me! You are going to kill me!" The client alternates yelling with mumbling and gesturing. Their eyes are darting back and forth as they are talking to the wall. The nurse should suspect the client has used which of the following substances? Anabolic steroids Opioids Stimulants Hallucinogens

Hallucinogens Hallucinogens can cause delusions, hallucinations, paranoia, problems thinking, and a sense of distance from one's environment.

A nurse is caring for a client who has ADHD. Which of the following findings should the nurse expect to observe? Hypohidrosis Hypoactivity Hyperactivity Hyperhidrosis

Hyperactivity Classic symptoms of ADHD include inattention, hyperactivity, and impulsivity.

A nurse is caring for a client who has dementia. Which of the following requests should the nurse make to determine the client's social cognition? Repeat a list of words Imitate gestures of learned movements Identify emotion of faces on cards Interpret a sequence of pictures

Identify emotion of faces on cards The nurse should determine the client's social cognition by requesting the client to identify emotion of faces on cards. The nurse can also use story questions to elicit information about the mental state of individuals within the story.

A nurse is providing medication education to clinicians who provide care at a local community health center. A small number of clients who regularly attend the community center identify as being part of an underrepresented culture. Which of the following benefits does the provision of culturally competent care provide to the client? If the client is comfortable, they are more likely to continue to seek treatment. Providing culturally competent care can reduce the client's feelings that they are risking relationships and jobs by seeking care. Receiving culturally competent care can reduce the chance that the client will need psychotropic medications. Without culturally competent care, the client might pay more out of pocket for treatment.

If the client is comfortable, they are more likely to continue to seek treatment. Culturally competent care can make clients feel more comfortable and can reduce incidents of bias. This makes it more likely that clients will continue to seek treatment.

A nurse is caring for a client who has anorexia nervosa. Which of the following findings should the nurse expect? Swollen parotid glands Hyperglycemia Hyperkalemia Lanugo

Lanugo Lanugo is a fine, downy hair that may grow on the face, back, and arms as a protective response to keep the body warm. This is an indication of anorexia nervosa.

A nurse is caring for a client who has experienced a stroke and exhibits parkinsonian effects. The client's cognition fluctuates. Which of the following types of dementia should the nurse expect the client to have? Frontotemporal lobar degeneration Lewy body disease Prion disease HIV infection

Lewy body disease The nurse should expect the client to have Lewy body disease dementia. Clients who have Lewy body disease dementia often experience a stroke and exhibit parkinsonian effects along with fluctuating cognition.

A nurse is caring for a client who is experiencing fluctuating cognition and visual hallucinations. Which of the following types of dementia should the nurse expect this client to have? Lewy body disease Traumatic brain injury HIV infection Prion disease

Lewy body disease The nurse should identify a client who is experiencing fluctuating cognition along with visual hallucinations might have Lewy body disease dementia. Other manifestations can include parkinsonism (bradykinesia, tremors, muscle rigidity), rapid eye movement during sleep, and neuroleptic sensitivity.

A nurse is assessing a client who is experiencing grief. The nurse should identify which of the following findings as an indication that the client has developed clinical depression? States that connecting with family is comforting Loss of interest in pleasurable activities Loss of appetite Has intense moments of sadness

Loss of interest in pleasurable activities Loss of interest in pleasurable activities

A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Nurses' Notes Day 2 1000: Client participating in group and individual therapy sessions. Client frequently speaks of the major loss of life associated with the COVID-19 pandemic. States, "I see their faces in my dreams at night." Client admits symptoms have worsened over the last few years, which is why they are currently seeking in-patient treatment. States, "I am so used to taking care of everyone else, I feel guilty having people take care of me." History and Physical Day 1 0900: 38-year-old nurse admitted with sleep disturbances including recurrent nightmares, detached feelings, continual fear, and hypervigilance. Client previously served in the armed forces as a combat medic and witnessed multiple injuries and death of fellow soldiers. Client has been working as a nurse for a local emergency department (ED) for the last 5 years and has provided care to many clients affected by the COVID-19 pandemic. The client asks the nurse, "Why did this happen to me?" The nurse should include which of the following in their response? Select all that apply. "Manifestations of PTSD are higher amongst military personnel

Manifestations of PTSD are higher amongst military personnel" is correct. Risk factors for PTSD include witnessing adverse events that happen to others and repeated exposure to adverse or traumatic events. Military personnel and healthcare workers are at a greater risk of developing PTSD because of the repeated exposure to stressful and adverse events. "Medical personnel working in EDs or ICUs have a high risk of developing PTSD" is correct. Risk factors for PTSD include witnessing adverse events that happen to others and repeated exposure to adverse or traumatic events. Military personnel and healthcare workers are at a greater risk of developing PTSD because of the repeated exposure to stressful and adverse events. "Witnessing the frequent loss of life is a high risk factor" is correct. Risk factors for PTSD include witnessing adverse events that happen to others and repeated exposure to adverse or traumatic events. Military personnel and healthcare workers are at a greater risk of developing PTSD because of the repeated exposure to stressful and adverse events.

A nurse is caring for a 10-year-old client who has sustained a life-threatening injury and is on life support. Discussion regarding the continuation of care and withdrawal of life-sustaining treatment have begun. The nurse should identify that which of the following people can be involved in making the decision to withdraw treatment? Dietitian Nurse Medical ethicist Provider Medical surrogate

Medical surrogate is correct. The family member or person who has medical surrogacy for the client should be involved in decision to remove life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity. Provider is correct. The medical provider who is directly involved in care of the client or is consulted should be involved in the decision-making regarding the withdrawal of life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity. Medical ethicist is correct. A medical ethicist may be consulted and is considered a member of the client's health care team involved with decision-making regarding the withdrawal of life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity. Nurse is correct. The nurse is a key member of the of the client's health care team involved with decision-making regarding the withdrawal of life-sustaining treatment. This represents an ethical approach to decision making and client rights and dignity .Dietitian is incorrect. The dietitian is not involved in decisions regarding the withdrawal of life-sustaining treatment.

A nurse is preparing a presentation about trauma for a group of newly licensed nurses. Which of the following should be included to describe prevalence of trauma and trauma-related events? More than 70% of adults worldwide have experienced trauma during their life. Of trauma- and stress-related disorders, post-traumatic stress disorder (PTSD) is the most common diagnosis. The LGBTQIA population experiences a higher occurrence of trauma-related disorders than the general population. Military personnel, first responders, and health care professionals are at higher risk of developing PTSD than the general population. Females are less likely to develop a trauma-related disorder than males. Most people who experience a trauma will develop a trauma-related disorder later in life.

More than 70% of adults worldwide have experienced trauma during their life is correct. The majority of adults worldwide will experience trauma during their lifetime. This can be a single event such as a car accident or repeated exposure to events, such as abuse. Of trauma- and stress-related disorders, post-traumatic stress disorder (PTSD) is the most common diagnosis is correct. PTSD is the most recognized and diagnosed disorder of the trauma-related disorders. The LGBTQIA population experiences a higher occurrence of trauma-related disorders than the general population is correct. Trauma-related disorders have been disproportionately diagnosed among people identifying as LGBTQIA when compared to the general population. This is thought to be related to a higher rate of traumatic exposure to discrimination and acts of violence. Military personnel, first responders, and health care professionals are at higher risk of developing PTSD than the general population is correct. Trauma-related disorders have been diagnosed at a higher rate among military personal, first responders (fire fighters, police), and health care professionals when compared to the general population. This is thought to be related to the exposure to trauma or traumatic events within the scope of their professions. Females are less likely to develop a trauma-related disorder than males is incorrect. Statistically, females are more than twice as likely to be diagnosed with PTSD compared to males. This is thought to be related to females experiencing higher rates of intimate partner violence or sexual assault.

Admission Assessment Day 1 1400: Client seen for annual physical. Client, age 56, no current health issues, lives at home and works full time. Family history of Alzheimer's disease Vital Signs Day 1 1405: Temperature 37.1° C (98.8° F) Blood pressure 110/80 mm Hg Heart rate 172/min Respiratory rate 16/min SaO2 98% on room air Provider Prescriptions Day 1 1445: Provide teaching on the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) The nurse is providing dietary teaching about the MIND diet to the client to promote cognitive function. Which of the following information should the nurse include in the teaching? (Select all that apply.) Use canola oil when cooking. Increase intake of berries. Substitute beans and lentils for meat at most meals. Limit or abstain from alcohol. Eat fish three times per week. Restrict intake of nuts.

My Answer When taking action and providing dietary teaching on the MIND diet, the nurse should include the use of olive oil for cooking, increasing intake of berries, limiting or abstaining from alcohol, eating fish once per week, replacing beans and lentils for meat for most meals, and eating nuts to promote cognitive function.

A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home? Necklace Lace-up tennis shoes Nylon socks Cotton underwear Glass framed picture of the client's partner

Necklace is correct. The nurse should identify that a necklace could be used to commit self-harm by a client who has suicide ideation. The necklace could be used as a choking device and should be sent home with the client's partner. Lace-up tennis shoes is correct. The nurse should identify that the laces of the tennis shoes could be used to commit self-harm by a client who has suicide ideation. The laces of the shoes could be used as a choking device and should be sent home with the client's partner. Glass framed picture of the client's partner is correct. The nurse should identify that a glass framed picture could be used to commit self-harm by a client who has suicide ideation. The glass could be used as a cutting device and should be sent home with the client's partner.

A nurse is caring for a client who has HIV infection dementia and has progressed to AIDS. Which of the following findings should the nurse expect? Weight gain Increased hemoglobin Night sweats Increased WBC count

Night sweats The nurse should identify that night sweats are a manifestation of AIDS. Other manifestations include fever, headache, weight loss, sore throat, and swollen lymph nodes.

A nurse is providing discharge teaching to a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take? Notify child protective services. Encourage the children to visit the psychiatric unit when the client is leaving. Suggest the children live with other relatives. Offer the client information about a support group for parents.

Offer the client information about a support group for parents. The nurse should identify that clients who have borderline personality disorder might have trouble controlling impulses, and a support group for parents could help the client build both parenting skills and interpersonal skills

A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to "eat clean." The nurse should identify that this is an indication of which of the following conditions? Anorexia nervosa Orthorexia Rumination disorder Pica

Orthorexia The nurse should identify that a client who has eliminated specific foods from their diet to "eat clean" may have orthorexia. Orthorexia is characterized by an obsession with "clean eating," which results in significant food restriction and malnutrition.

A nurse is reviewing the medical record of a client who is being admitted with dementia. The nurse notes that the client has worked as a pest control specialist for the last 20 years. Which of the following types of dementia should the nurse expect the client to be experiencing? Frontotemporal lobar Alzheimer's disease Prion disease Parkinson's disease

Parkinson's disease The nurse should expect that a client who has dementia and has worked with pesticides for the past 20 years might have Parkinson's disease dementia. Working with herbicide and pesticides are related to client's who have Parkinson's disease dementia.

FLA nurse is caring for a client who has posttraumatic stress disorder (PTSD). The nurse anticipates the provider might prescribe which of the following medications? Tramadol Semaglutide Zaleplon Paroxetine

Paroxetine The first treatment for PTSD is a selective serotonin reuptake inhibitor (SSRI), such as paroxetine.

A nurse is discussing the official American Nurses Association position on capital punishment with a coworker. Which of the following statements by the nurse indicates an understanding of the American Nurses Association's (ANA) position? The role of the nurse is to facilitate justice as defined by the United States and the state in which they are employed. Participation, directly or indirectly, in the execution of a human being goes against nursing core values. A prison nurse has specific duties, among which is the preparation and support of the individuals awaiting execution. A nurse must set aside personal values and provide care based on the setting in which they work.

Participation, directly or indirectly, in the execution of a human being goes against nursing core values. The American Nurses Association (ANA) opposes both capital punishment and nurse participation in capital punishment.

A nurse is teaching a group of newly licensed nurses about personality disorders. Which of the following information should be included? Personality disorders often manifest from childhood emotional trauma. Clients of higher socioeconomic status are less likely to be diagnosed with personality disorders. Personality disorders are often seen in children under the age of 10. Strict parental guidelines contribute to the development of personality disorders.

Personality disorders often manifest from childhood emotional trauma. CORRECT The nurse should identify that environmental risk factors for personality disorders include physical, emotional, verbal, and sexual abuse, neglect, and hostility. These risk factors can occur at any age but are especially prominent when experienced during childhood.

A nurse is assisting with the admission of several clients. Plan of Care Plan of Care Admission Day 1 0900: Collect data from clients. Observe for physical signs such as shakiness, moist or cool hands, needle track marks, hyperactivity, and poor hygiene. Behavioral signs may include a poor attention span, forgetfulness, irritability, poor job performance, losing a job, poor performance at school, possession of drugs and drug paraphernalia, and drug seeking behaviors. Based on data, prioritize hypothesis regarding clients' risks, needs, and manifestations of disease processes. 1200: Plan care for clients and generate solutions to identified problems. Consider the client's preferences, wishes, and needs along with any spiritual, ethical, or cultural preferences when creating an unbiased plan, which is individualized to the specific client. Implement the plan of care and take actions to utilize identified nursing interventions to meet client needs. Day 2: Evaluate client outcomes and determine if plan of care needs to be altered or modified. A charge nurse is assisting a newly licensed nurse with the admission of two clients. The charge nurse is discussing the nursing process with the newl

Planning should be initiated upon admission is correct. The planning is done initially upon entrance into a facility or program. It is evaluated and updated throughout the client's time within the facility or program. Prioritizing hypothesis allows the nurse to determine immediate care needs is correct. Based on the data collected, the nurse will determine the client's problems, which will help the team of health care professionals involved in the client's care to make decisions about treatment.

A nurse should identify that which of the following factors is a protective factor that prevents adults from developing addictions? Positive self-image Single status Passive personality Being a parent

Positive self-image This is identified as being protective factor to potentially keep adults from developing addictions.

A nurse is providing care to a 9-year-old child who uses their hand to mimic shooting a gun anytime someone enters the room or tries to interact with them. The nurse should identify that this is an example of which of the following manifestations of post-traumatic stress disorder? Posttraumatic play Time skewing Depersonalization Omen formation

Posttraumatic play This child is exhibiting posttraumatic play, or reenactment of a traumatic event, in which the child repeatedly mimics some aspect of the trauma.

A nurse is caring for a client who is exhibiting a depressed mood one week before the start of their menstrual cycle. The nurse should identify that the client is exhibiting manifestations consistent with which of the following disorders? Postpartum depression Premenstrual dysphoric disorder Cyclothymic disorder Bipolar disorder

Premenstrual dysphoric disorder The nurse recognizes that the depression experienced in premenstrual dysphoric disorder occurs in the week before a client menstruates.

Which of the following risk factors should a nurse associate with ADHD? Hispanic ethnicity High birth weight Prenatal exposure to alcohol or tobacco High-sugar diet

Prenatal exposure to alcohol or tobacco Strong evidence supports that prenatal exposure to alcohol or tobacco is an identified risk factor for ADHD.

A nurse is caring for a client, in an outpatient setting, who is experiencing poor appetite, fatigue, and thoughts of hopelessness. The nurse uses the SAD PERSONS scale to further assess. Which of the following items is included in SAD PERSONS? Previous suicidal ideation History of childhood abuse Parent with history of suicide Previous attempt of suicide

Previous attempt of suicide The nurse should identify that the SAD PERSONS scale does include the risk factor of a previous attempt of suicide as an item. Each risk factor is one point, and the total scale score is calculated to assist in determining need for referral or admission.

A nurse is caring for a client who is experiencing lack of sleep, lack of appetite, and difficulties with concentration. Which of the following types of dementia should the nurse expect this client to have? Prion disease HIV infection Frontotemporal lobar degeneration Traumatic brain injury

Prion disease The nurse should identify a client who is experiencing lack of sleep, lack of appetite, and difficulties with concentration might have prion disease dementia. Other manifestations can include fatigue, lack of coordination, anxiety, and abnormal movements.

A school nurse is creating a support group for students following the suicide of one of their peers. Which of the following interventions is the nurse providing? Strengthening economic supports Promoting connectedness Creating protective environments Strengthening access to suicide care

Promoting connectedness By providing a support group to assist the students with the death of their peer, the nurse is promoting connectedness.

A nurse is working with a client and their partner. Which of the following information describes the reason it is important to recognize early warning signs related to substance use? Recognizing early warning signs allows law enforcement to make arrests that lead to forced treatment. Recognizing early warning signs can lead to early intervention and better outcomes. Recognizing early warning signs allows the client time to institute or make changes to end-of-life legal documents, such as a living will. Recognizing early warning signs allows the client's family to stage an intervention run by family members and other loved ones.

Recognizing early warning signs can lead to early intervention and better outcomes. This is not a reason for identifying early warning signs of a substance use disorder.

A nurse is discussing the plan of care with the guardians of a child recently diagnosed with a neurodevelopmental disorder. The guardians tell the nurse that they are opposed to any medication intervention. Which of the following actions should the nurse take? Recommend the use of nonpharmacological interventions to the child's provider Suggest that the guardians find a new health care provider that will comply with their wishes for treatment. Tell the guardians that medication intervention will be necessary to proceed with the child's care. Educate the guardians about the possible effects and tolerability of medication intervention for their child.

Recommend the use of nonpharmacological interventions to the child's provider Gardians' preferences should be considered when creating a treatment plan. If parents refuse a particular treatment, the nurse should investigate the reasons behind the refusal then work with parents to provide treatment that is acceptable to them.

A nurse is discussing relapse potential with a group of clients and their families. The nurse should include which of the following statements about relapse prevention? Relapses should be expected and be looked at as an opportunity. Relapses signal failure of the abstinence plan, and the plan must be changed. Relapses may indicate that the client has very little willpower. Relapses are rare and unlikely to occur.

Relapses should be expected and be looked at as an opportunity. Many clients with substance use disorders go through periods of sobriety and then relapse, only to repeat this pattern. Relapse should not be thought of total failure, but rather an opportunity to begin again on their sobriety journey. The most important thing is the trend—that clients are staying sober for longer periods of time and relapsing less often as time goes by, leading to a completely sober lifestyle eventually.

A nurse is planning for a therapy dog to visit a client who has dementia. Which of the following is the purpose for this activity?

Relax the client The nurse should identify that pet therapy can assist clients who have dementia to relax and cope.

A staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action? Agree to not report the incident if the coworker promises to report themselves to the supervisor. Report the incident to the appropriate person in the chain of command right away. Report the incident to the other RNs on the shift. Agree to not report the incident if the coworker seeks treatment.

Report the incident to the appropriate person in the chain of command right away. This is the action the nurse should take. Nurses have a professional duty to report impairment to the appropriate chain of command so that client safety can be maintained. One important action you as a nurse must take if you suspect a peer nurse is impaired, or if you witness a peer nurse using drugs or alcohol at work, is to report this. Many people have negative feelings about 'telling' or reporting on someone. Nurses may fear negative consequences such as being perceived as a "snitch", getting

A nurse is admitting a client who has end-stage chronic obstructive pulmonary disease (COPD) and has been intubated on previous hospitalizations. The client refuses intubation and any invasive treatment. Which of the following client rights is the client exercising? Right to medical records Right of autonomy Right of justice Right of confidentiality

Right of autonomy The client is exercising their right to determine their own care and treatment. The nurse should advocate for the client and support the client's right of autonomy or self-determination.

A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse what type of essential oils should be used when the client receives massage therapy to decrease anxiety. Which of the following oils should the nurse recommend? Eucalyptus Rosemary Frankincense Cypress

Rosemary The nurse should recommend the use of rosemary oil. Essential oils such as rosemary, lemon, and lavender are effective when used during massage to decrease anxiety, improve sleep, and improve cognitive function for clients who have Alzheimer's disease.

A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include? Harvard Implicit Association Test (IAT) SAFE-T Altman Self-Rating Mania Scale SAD PERSONS PHQ-9

SAFE-T is correct. The SAFE-T assessment addresses a client's level of suicide risk and offers interventions. SAD PERSONS is correct. The SAD PERSONS scale is a suicide risk assessment that utilizes an acronym for easy learning. The scale is based on 10 major risk factors.

A nurse is caring for a client who states, "I have no interest in sexual activity or finding a partner." The nurse should identify that this statement is consistent with which of the following personality disorders? Antisocial personality disorder Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder

Schizoid personality disorder The nurse should identify that schizoid personality disorder is characterized by a desire to be alone and disinterest in intimate, social, or meaningful relationships.

A nurse is caring for a client who screams, "I can read your minds!" The nurse should identify this finding as a manifestation of which of the following personality disorders? Schizotypal personality disorder Paranoid personality disorder Antisocial personality disorder Avoidant personality disorder

Schizotypal personality disorder The nurse should identify that schizotypal personality disorder is often characterized by a belief that one has magical powers.

A nurse is meeting with a new client at a substance use disorder clinic. Prior to the client meeting, the client's family shared information with the nurse about the client. Which of the following describes the types of data from the client's family? Secondary Objective Subjective Historical

Secondary Secondary data is information obtained from someone other than the client, such as family members.

A nurse assigned to a mental health hotline receives a call from a nurse who has been working on a Covid-19 unit. The caller states, "I just don't think I can be a nurse anymore." Which of the following types of trauma should the nurse recognize this person is experiencing? Acute trauma Chronic trauma Complex trauma Secondary trauma

Secondary trauma Nurses and other health care professionals are at risk for secondary trauma due to the repeated witnessing of client trauma and death. Incidents of secondary trauma have increased during the Covid-19 pandemic.

A nurse is caring for a child whose guardians report that the child is consistently unable to speak during class and other social situations. The nurse should identify that the child is experiencing which of the following anxiety disorders? Generalized anxiety disorder Agoraphobia Separation anxiety disorder Selective mutism

Selective mutism The nurse should identify that the child is experiencing selective mutism. Clients who have selective mutism demonstrate consistent failure to speak in specific social situations.

A nurse is caring for a client who has posttraumatic stress disorder (PTSD) and is beginning psychopharmacology therapy. Which of the following medications is considered first-line treatment for symptoms of PTSD? Olanzapine Haloperidol Prazosin Sertraline

Sertraline Sertraline is a selective serotonin reuptake inhibitor (SSRI). SSRIs are considered a first-line treatment for PTSD symptoms of depression and anxiety.

A nurse is contributing to the plan of care for a recently admitted client who has bulimia nervosa. Which of the following interventions should the nurse recommend including in the plan of care for the first week of hospitalization? Permit the client to select their own meals. Assign the client independent bathroom privileges. Supervise the client during mealtimes. Punish the client for purging behavior.

Supervise the client during mealtimes. A newly admitted client who has bulimia nervosa should be closely supervised during mealtimes to ensure they are not engaging in harmful behaviors related to eating.

A nurse is reviewing strategies with a client who has a neurodevelopmental disorder to help them become more independent. Which of the following phases of the nurse-client relationship does this represent? Exploitation phase Identification phase Orientation phase Termination phase

Termination phase An important final treatment goal for clients with neurodevelopmental disabilities is achieving, as much as possible, a degree of independent functioning.

A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct? The amygdala-centered (ACC) circuit of the brain is associated with feelings of panic. The amygdala-centered (ACC) circuit of the brain is associated with feelings of apprehension. The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is associated with phobias. The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is associated with feelings of fear.

The amygdala-centered (ACC) circuit of the brain is associated with feelings of panic. The ACC is associated with manifestations such as fear, panic, and phobia.

A nurse is reviewing assessment findings for a 9-year-old child whose family home was destroyed in a wildfire. The nurse should identify that which of the following behaviors is related to the traumatic experience? The child insists on having their own way when playing with friends. The child is rude to their siblings when things do not go their way. The child is found making small fires in the backyard. The child cries because they are the smallest child in their class.

The child is found making small fires in the backyard. Children often reenact trauma through play; this is a clinical manifestation of trauma. The parents should seek follow-up care and further education on clinical manifestations of trauma.

A nurse is reviewing the documentation for a newly admitted client and notes the following entry, "Client verbalizes the use of coping mechanisms when experiencing stress." Which of the following can the nurse expect when interacting with this client? The client prefers solitary activities to group activities. The client follows all rules. The client adapts well to change. The client prefers to sit quietly.

The client adapts well to change. The nurse should identify that clients who develop healthy coping mechanisms are able to de-escalate their vulnerability to certain illnesses, such as personality disorders.

A nurse is providing care to a client who has dyslexia. Which of the following findings would the nurse expect to observe? The client is unable to write in cursive. The client is unable to communicate through writing. The client has difficulty solving math problems. The client has difficulty reading.

The client has difficulty reading. Dyslexia is a specific learning disorder that impairs reading and comprehension. Individuals who have dyslexia might find it difficult to pronounce words, identify letters, and understand what they have read. Frequent and recurrent use of oral language skills and the contextualization of letters through writing and reading can help learners.

A nurse is caring for a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication of refeeding syndrome? The client reports a sudden increased energy level. The client reports increased appetite at bedtime. The client had a weight gain of 0.91 kg (2 lb) over 1 week. The client has peripheral edema of both legs.

The client has peripheral edema of both legs. Clients who have anorexia nervosa can experience heart muscle atrophy due to prolonged starvation. As a result, the heart can become overloaded with the restart of fluid and nutritional intake, leading to edema, severe electrolyte imbalances, and potential cardiac collapse. Edema is an early indication of refeeding syndrome that should be reported to the provider immediately.

A nurse is caring for a client who was admitted to the emergency department with a blood alcohol content of 0.15 mg/dL. Which of the following conclusions should the nurse make about the client's blood alcohol content? The client needs inpatient treatment for their drinking problem. The client has a substance use disorder. The client ingested enough alcohol to cause them to experience acute cognitive impairment. The client has been a heavy drinker over the past few months.

The client ingested enough alcohol to cause them to experience acute cognitive impairment. This is the correct analysis. Nothing else can be inferred from the information given.

A nurse is developing a plan of care for a client who was recently diagnosed with a trauma-related disorder. Which of the following client goals should the nurse include? The client will develop effective coping strategies by discharge. The client will identify triggers for traumatic reexperiencing by discharge. The client will participate in developing their plan of care. The client will avoid discussion of traumatic experience. The client will identify appropriate resources to help in restoring normal routines. The client will use exact medical language when explaining trauma.

The client will develop effective coping strategies by discharge is correct. The nurse should help the client identify effective coping strategies to help empower them and restore normal routines. The client will identify triggers for traumatic reexperiencing by discharge is correct. They will also identify strategies for self-regulation they can use if they are triggered. The client will participate in developing their plan of care is correct. The client should participate in the development of their treatment plan because this will help empower them. The client will identify appropriate resources to help in restoring normal routines is correct. The client should participate in identifying appropriate resources they can use to help restore normal routines. Having the client participate in their plan of care empowers them to make choices that are right for them.

A nurse is educating a group of clients about addiction. The nurse should include that which of the following factors increases the potential for addiction? Medical insurance availability for substance use disorder treatment. The developing brain is exposed to substances at an early age. The brain already has cognitive deficits that causes it to be vulnerable to addiction. Initial use of substances began in adulthood.

The developing brain is exposed to substances at an early age. The risk for addiction is heightened when the developing brain is exposed to substances.

A charge nurse is observing a newly hired nurse provide grief-informed care for a client. Which of the following actions by the newly hired nurse requires follow-up by the charge nurse? The nurse determines the effect the death or loss has had on the client. The nurse asks the client why they require care or assistance. The nurse acknowledges that the client experienced a death or loss. The nurse advocates for the client to receive bereavement support.

The nurse asks the client why they require care or assistance. "Why" questions can be interpreted as judgmental and do not represent a grief-informed approach. A grief-informed approach focuses on what occurred (trauma or loss), where the trauma or loss took place, and how the trauma or loss affects the client's current condition or situation.

A nurse in a pediatrician's office is caring for a preschooler. Nurses' Notes 3-year-old well-child visit Child checks in with guardian for annual physical exam. Guardian reports child has had no illnesses other than a mild upper respiratory infection 2 months ago. Child playing with toys in exam room and answers questions appropriately. Language and motor skills appropriate for age. 4-year-old well-child visit Child in exam room with guardian for annual exam. Child noted to be restless, unable to sit in chair for more than a minute or two before getting up. Child frequently interrupting conversation between nurse and guardian and requires frequent redirection. Guardian states the child "has always been a busy kid, but it seems that it is getting worse." Guardian reports the child began preschool a few weeks ago and the teacher has sent several notes home that the child is often interrupting class and has difficulty following directions. Flow Sheet 3-year-old well-child visit Height 95 cm (37.5 in) Weight 14.5 kg (32 lb) 4-year-old well-child visit Height 101.6 cm (40 in) Weight 14.5 kg (32 lb) Vital Signs 3-year-old well-child visit Heart rate 98/min BP 91/48 mm Hg Respiratory rate 22/m

The nurse should analyze cues and determine that the child is exhibiting manifestations of attention deficit hyperactivity disorder (ADHD). The nurse should further assess the child by performing a developmental screening using a standardized assessment tool. The nurse should then discuss behavioral interventions with the guardian when implementing interventions for addressing the child's behaviors at home and school.

A nurse is caring for a school-aged client. Nurses' Notes 0900: School aged client brought to the clinic by parents directly from school for physical aggression toward peers. 1000: The child begins screaming and hitting their parents. The parent begins to cry and states, "I just do not know what to do anymore. I cannot take this." History and Physical School-aged client has been hospitalized four times this year for extreme irritability and temper tantrum-like episodes, leading to risk to self and others. Social history: Client lives with their mother, stepfather, and two older siblings in middle class neighborhood. Parents amicably divorced around age 3 years. Client visits father every other weekend. Siblings are reportedly healthy and perform well in school. No history of psychiatric illness in family. Client met developmental milestones on time. Behavioral difficulties began around age 4. Once client entered school, stubbornness and irritability increased. Client's temper episodes occur at home, biological father's home, and school. Outbursts typically last for 30 min but could last up to 2 hr at both home and school. At home, client's siblings "walk on eggshells" in fear of upsettin

The nurse should analyze cues to compare client findings to evidence-based resources and standards of care. The client is at risk for developing disruptive mood dysregulation disorder due to severe, recurrent outbursts out of proportion to the situation. Other diagnostic criteria for disruptive mood dysregulation disorder include onset of symptoms before the age of 10, but diagnosis is made between the ages of 6 and 18 years of age. Symptoms must be present for 12 months or more, and symptoms should be present in at least two settings.

A nurse on an inpatient mental health unit is assisting with a series of group therapy sessions for a small group of clients. Nurses' Notes Nurses' Notes Session 1: Client A states they are fearful at times. Client B is sobbing and states they can't go a day without their partner. Client C remains silent during the session. Client D wears boots 24 hr per day. Client E continuously twists their hair. Session 4: Client A admits to having an extreme fear of mice, among other things. Client B brings a picture of their partner to the session and cries when looking at the photo. Client C has yet to speak during a group session. Client D tells the group they wear boots all the time because they have the world's ugliest feet and don't want anyone to see them. Client E is now pulling out hair after they have twisted it. The nurse is reviewing the observations made from the various group sessions. Drag words from the choices below to fill in each blank in the following sentences. 1. Client A is exhibiting manifestations of Target 1 . 2.Client B is experiencing manifestations of Target 2 . 3. Client C continues to exhibit manifestations of Target 3 . 4. Client D is displaying manifestations of Ta

The nurse should recognize cues to determine that client A is exhibiting manifestations of murophobia, or a fear of mice, while client B is experiencing manifestations of separation anxiety. Client C continues to exhibit manifestations of mutism. Client D is displaying manifestations of body dysmorphia and client E has worsening manifestations that have progressed to trichotillomania. Per the Diagnostic and Statistical Manual (DSM) for Mental Disorders, murophobia, separation anxiety, and mutism are a subclass of anxiety disorders, while body dysmorphia and trichotillomania are a subclass of obsessive-compulsive and related disorders.

A nurse has been confronted about stealing and taking drugs from the narcotics cart in the med room. The nurse has been reported to the board of nursing in their state. What is the likely initial outcome? The nurse will be assisted into drug treatment. The nurse will need to transfer to a different unit. The nurse will be fired immediately The nurse will lose their nursing license immediately.

The nurse will be assisted into drug treatment. Most states have programs in place to assist the impaired nurse to recover without having to lose his/her nursing license. These diversion programs can assist the nurse to begin treatment, and they may be able to continue working with restrictions, such as not being able to give narcotics.

A nurse on an inpatient unit is creating an educational presentation on bipolar disorder. Which of the following should the nurse plan to include in the presentation? More women than men have been diagnosed with bipolar disorder. The prevalence of bipolar disorder in adults is estimated at 2.8%. More adolescents than adults are diagnosed with bipolar disorder. The prevalence of bipolar disorder in adults is estimated at 8.2%.

The prevalence of bipolar disorder in adults is estimated at 2.8%. The nurse should identify that the prevalence of bipolar disorder in the United States among adults aged 18 or older is estimated to be at 2.8%, affecting 2.9% of men and 2.8% of women.

A nurse is discussing common misconceptions regarding clients who have substance use disorder. The nurse should include which of the following as a potential negative result of providers believing that addiction is the client's own fault? The provider may deny care or deliver poor quality of care. The client may increase their substance use dramatically. The provider may choose to abuse substances. The client may ask for residential treatment instead of outpatient treatment.

The provider may deny care or deliver poor quality of care. This answer correctly identifies that when providers think that addiction is the client's own fault, they might deliver care that is substandard and at times deny care altogether.

Which of the following describes the alternative-to-discipline program? A new initiative being studied by boards of nursing A pilot program designed to facilitate addiction prevention The standard to help nurses into recovery A research project facilitated by the federal government

The standard to help nurses into recovery An alternative-to-discipline (ATD) program is one in which the nurse who has had a substance use disorder will not practice nursing for a designated time while being involved in a recovery program or undergoing treatment. These are actually the standard for use in recovery for nurses with a substance use disorder, because they have been shown to be effective.

A nurse is caring for a client who reports spending 12 hr daily playing video games online. The client has spent a significant amount of money betting on these games. They lost their job due to missed work, and they filed for bankruptcy because of their gambling debts. Their partner was supporting them financially until the partner left the client out of frustration with their behavior. Which of the following manifestations of non-substance addiction is characteristic of the client's behavior? They filed for bankruptcy because of their debts and job loss. They do not care that they lost their job and their partner. They compulsively act on the urge to continue internet gaming and gambling even though they suffered negative consequences. They are depressed over their current life situation.

They compulsively act on the urge to continue internet gaming and gambling even though they suffered negative consequences. CORRECT One manifestation of non-substance addiction is continuing the behaviors even though they have negative consequences.

A nurse is caring for an adolescent client whose close friend recently died by suicide. The client tells the nurse, "I should have called back when they texted me. If I had been there, my friend would still be alive." Which of the following information should the nurse understand from this statement? This is an expression of a lack of self-compassion, and the client needs to focus on being kind to themselves. This is an expression of delayed grief response, and the client is expressing their thoughts and feelings. This is an expression of emotional pain, and the client needs to be closely monitored. This is an expression of normal grief, and the client will respond well if they can just express their feelings.

This is an expression of emotional pain, and the client needs to be closely monitored. This is emotional pain and feelings of guilt from a traumatic loss. It is important for this client to be closely monitored for safety.

A nurse is responding to a parent of an adolescent who was recently diagnosed with posttraumatic stress disorder following a sexual assault. The parent states, "My child ignores curfew, is hanging out with a rough crowd, and has been experimenting with drugs. Why would they be doing this?" Which of the following responses should the nurse make? "It is very frustrating when children misbehave. Do any of your other children react the same way? What rules have you established for them?" "This must be a difficult time for you. Adolescents who have experienced a trauma may exhibit increased reckless behaviors." "This is normal behavior for an adolescent. Nothing to be concerned about." "I can understand your concerns. Which of these behaviors do you want to address first?" I

This must be a difficult time for you. Adolescents who have experienced a trauma may exhibit increased reckless behaviors." This is the most appropriate response because it is therapeutic and responds to the parent's question. Adolescents who have experienced trauma may respond in reckless behaviors.

A nurse is interacting with a client. The client repeatedly shrugs and yells out random words. The nurse recognizes that this finding is associated with which of the following disorders? Attention-deficit/hyperactivity disorder (ADHD) Autism spectrum disorder (ASD) Tourette syndrome Expressive language disorder

Tourette syndrome Clients who have Tourette Syndrome can have vocal tics or sounds that are not associated with purposeful communication.

A nurse in an emergency department is assessing a client who has a personality disorder and reports that they recently used illicit drugs. Which of the following screening tools should the nurse use to determine if the client has recently used an illicit substance? Minnesota Multiphasic Personality Inventory (MMPI) Personality Diagnostic Questionnaire Eysenick Personality Inventory Toxicology test

Toxicology test The nurse should identify that the Minnesota Multiphasic Personality Inventory (MMPI), the Eysenick Personality Inventory, and the Personality Diagnostic Questionnaire are the instruments used to diagnose personality disorders. Toxicology tests are used to evaluate for substance use.

A nurse is providing dietary teaching to a client who has been diagnosed with Alzheimer's disease about including foods to decrease the progression of the disease. Which of the following foods should the nurse recommend? Tuna sandwich Hamburgers Turkey sandwich Cheese pizza

Tuna sandwich The nurse should recommend tuna sandwiches for the client. Fish is high in omega-3 fatty acids, which can delay or slow the progression of the disease.

A nurse is planning care for a client who has Alzheimer's disease and is in the terminal phase. Which of the following findings should the nurse expect? Unable to sit up Requires cueing to eat Needs assistance with finances Speech degrades to a few words

Unable to sit up The nurse should identify that a client who is unable to sit up is in the terminal phase of Alzheimer's disease. Other manifestations can include the client not being unable to hold their head up or smile, requiring total care, and assuming the fetal position when lying down.

A nurse is caring for a client following an attempted suicide. The client states, "I can't live with killing my son. I was drunk and he was in the car. It is all my fault" Which of the following considerations focuses on universal trauma precautions in the care of this client? Use therapeutic communication in all encounters. Establish an environment where the client feels safe. Acknowledge that the client has experienced trauma. Avoid blaming or shaming the client for mental health behaviors. Collaborate with the interdisciplinary team.

Use therapeutic communication in all encounters is correct. Universal trauma precautions are the basis for providing trauma-informed care and include using therapeutic communication in all client encounters. Establish an environment where the client feels safe is correct. Universal trauma precautions are the basis for providing trauma-informed care. This includes creating a safe environment where the client can heal. Acknowledge that the client has experienced trauma is correct. Universal trauma precautions are the basis for providing trauma-informed care. This includes the healthcare team members acknowledging the client's trauma. Avoid blaming or shaming the client for mental health behaviors is correct. Universal trauma precautions are the basis for providing trauma-informed care. This includes addressing the client with respect and without judgement, blame, or shame.

A nurse in the emergency department (ED) is caring for a client. Laboratory Results 1130: Complete Blood Count: Hgb 9 g/dL (12 to 18 g/dL) Hct 28% (37% to 52%) Total WBC count 4,000/mm3 (5,000 to 10,000/mm3) Platelet count 130,000/mm3 (150,00 to 400,000/mm3) Basic Metabolic Profile: Creatinine 0.8 mg/dL (0.5 to 1.0 mg/dL) BUN 19 mg/dL (10 to 20 mg/dL) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Vital Signs 1500: Heart rate 52/min Respiratory rate 28/min Blood pressure 74/50 mm Hg Temperature 36.1° C (97° F) SaO2 90% on 2 L/min via nasal cannula Nurses' Notes 1515: Client arrived at the ED via ambulance. Emergency medical technicians (EMTs) state the client fainted at place of employment while walking down a flight of stairs. Client fell and rolled down several steps. Coworkers called for an ambulance. Client was awake upon EMTs arrival. Client oriented to person, place, time, but appears lethargic. Reports dizziness and headache. No injury noted from fall. Client states, "I think I just haven't eaten enough today. That must be why I passed out." Client states they have passed out numerous times in the past month. Reports only eating one meal a day for the past few months because they have been

Using the airway, breathing, circulation (ABC) priority framework, the nurse should first take action and address the client's oxygenation status of labored respirations, an SaO2 below the expected reference range, and the client's report of shortness of breath by increasing the amount of supplemental oxygen they are receiving. The client's complete blood count indicates the client is experiencing anemia, which can account for their compromised respiratory status. The next finding the nurse should address is the client's blood pressure, which indicates hypotension. The client's fainting and report of dizziness may be a result of the hypotension they are experiencing. The client will require the initiation of IV fluids to replace their low circulating fluid volume.

A nurse manager is reviewing a recent client report related to a staff nurse. Which of the following behaviors by a nurse at work might be red flags for a substance use disorder? Volunteering for overtime on a continual basis, avoiding having a witness to wasting narcotics, needing to be alone in the medication room when preparing medications. Manipulation Crying, sharing personal details of relationship problems, monopolizing conversations. Increased cheerfulness, increased energy, helping other nurses on the shift.

Volunteering for overtime on a continual basis, avoiding having a witness to wasting narcotics, needing to be alone in the medication room when preparing medications. Some concerning behaviors include volunteering for overtime and coming to work on days not working. This may suggest that the nurse is diverting prescription drugs from the medication room. The nurse may also avoid having a witness to verify unused medication wasting or waiting to be alone with the narcotic box or alone in the med room. They might be volunteer to administer controlled substances or behave in a suspicious manner when the narcotic counts are incorrect.

A nurse is caring for a client who is receiving life-sustaining treatmen Medical History Day of admission: A 10-year-old client was hit by a car while riding their bike in their neighborhood. Sustained skull fracture, subdural basal hematoma, multiple fractures to both lower extremities, and ruptured spleen. Splenectomy performed, fractures set, and client placed in pediatric ICU on mechanical ventilator. Non-responsive. Vital signs stable. Initial electroencephalogram (EEG) shows no evidence of brain activity. Day 2: No change in status. Unresponsive to tactile stimuli. No purposeful movement noted. No spontaneous breaths. Day 3: Repeat Magnetic Resonance Imaging (MRI) reveals epidural hematoma and generalized cerebral swelling. Unresponsive to tactile stimuli. No purposeful movement noted. No spontaneous breaths. Decreased heart rate and widened pulse pressure consistent with increased intercranial pressure. Repeat EEG flat - no brain activity. Day 4: Client remains nonresponsive. Blood pressure dropping and heartrate decreasing over last 24 hr. Pupils fixed and dilated. No attempt at spontaneous breathing noted. Third EEG flat - no brain wave activity noted. Family conference called t

When analyzing cues, the nurse should anticipate experiencing feelings of grief and moral distress. The nurse should share these feelings in a debriefing meeting with other nursing staff. Debriefing can be beneficial to the nurse by providing a space for the nurse to express their feelings with the support of their peers. Withdrawing treatment when caring for a client can be emotionally and morally difficult and draining on the nurse.

Admission Assessment Day 1 0900: Client has ulcerative colitis and depression. Client's family states the client has been vomiting and experiencing diarrhea with limited food and fluid intake for the last 3 days. Client recently increased dosage of acetaminophen and increased dosage of prednisone. Urinary output is less than 30 mL/hr for past 2 hr. Client confused to person, place, and time. Medication Administration Record Day 1 0905: Prednisone 40 mg PO daily Lorazepam 0.5 mg PO every 6 hr or as needed for anxiety Amitriptyline 50 mg PO daily Acetaminophen 650 mg PO every 6 hr or as needed for pain Laboratory Results Day 1 0910: Review of Laboratory Results 3 months ago Potassium 4.5 mEq/L (3.5 to 5.0 mEq/L) Sodium 143 mEq/L (135 to 145 mEq/L) Chloride 106 mEq/L (98 to 106 mEq/L) Total calcium 9 mg/dL (9.0 to 10.5 mg/dL) Magnesium 1.6 mEq/L (1.3 to 2.1 mEq/L) Creatinine 1.5 md/dL (0.7 to 1.3 mg/dL) BUN 21 mg/dL (10 to 20 mg/dL) Day 1 1200: Potassium 5.1 mEq/L (3.5 to 5.0 mEq/L) Sodium 146 mEq/L (135 to 145 mEq/L) Chloride 115 mEq/L (98 to 106 mEq/L) Total calcium 8 mg/dL (9.0 to 10.5 mg/dL) Magnesium 2.0 mEq/L (1.3 to 2.1 mEq/L) Creatinine 1.9 mg/dL (0.7 to 1.3 mg/dL) BUN 25 mg/dL (10

When analyzing cues, the nurse should determine the cause of delirium. The nurse should review the client's medication and look for use of corticosteroids, antidepressants, and benzodiazepines as these medications can cause delirium. Electrolyte imbalances : Potassium 5.1 mEq/L (3.5 to 5.0 mEq/L)Sodium 146 mEq/L (135 to 145 mEq/L)Chloride 115 mEq/L (98 to 106 mEq/L) otal calcium 8 mg/dL and dehydration should also be monitored and treated. Manifestations of dehydration include increased urine specific gravity, decreased urinary output, increased creatinine levels, and increased BUN, which can cause delirium. These findings can be associated with hypotension, tachycardia, and a decreased oxygen saturation level.

A nurse in a pediatrician's office is caring for a preschooler. Nurses' Notes Initial visit Parent brought child in for evaluation at recommendation of preschool teacher. Parent reports that the teacher has concerns about the child's inability to sit still, focus on conversation, and complete simple tasks without distraction. The child is noted to be restless in the exam room and frequently interrupts during conversation. Discussed behavioral interventions to address behavior, parent voices understanding. 2-month follow-up visit Child remains restless and is easily distracted. Child often does not notice when being spoken to due to distractions and frequent talking to self. Parent reports using recommended behavioral interventions regularly but has seen no change in the child's behavior. Vital Signs Initial visit Heart rate 108/min Respiratory rate 22/min Temperature 36.7° C (98° F) 2-month follow-up visit Heart rate 112/min Respiratory rate 24/min Temperature 37.1° C (98.8° F) Which of the following medications should the nurse identify as being a potential treatment for this child? Methylphenidate Atomoxetine Clonidine Dextroamphetamine Selegiline

When analyzing cues, the nurse should identify that the child is exhibiting manifestations of attention deficit hyperactivity disorder, or ADHD. Manifestations of ADHD include hyperactivity, distractibility, inattention, and impulsive behaviors. Psychostimulant, selective norepinephrine reuptake inhibitors (SNRIs), and alpha-2 adrenergic agonists are types of medications used to treat ADHD. Methylphenidate and dextroamphetamine are psychostimulants, atomoxetine is an SNRI, and clonidine is an alpha-2 adrenergic agonist. Therefore, the nurse should identify these medications as potential treatments for this child.

A nurse is providing care to a client who experienced the loss of their partner. Vital Signs Day 1 0730: Temperature 36.6° C (97.8° F) Pulse rate 74/min Respiratory rate 16/min BP 118/74 mm Hg Day 2 0730 Temperature 36.9° C (98.4° F) Pulse rate 92/min Respiratory rate 18/min BP 98/72 mm Hg Medical History Day 1 0900: A 58-year-old client admitted for evaluation, accompanied by family members. Client has become more isolated over the last 15 months since their partner was killed in a motor-vehicle crash. Client acknowledges they just, "can't snap out of this funk." Client says most days they have severe longing for their partner and cannot imagine life without them. Client states, "my heart is broken and sometimes I just cannot catch my breath." Client refuses to discuss circumstances surrounding the death of their partner, but does keep pictures and other mementos as reminders of their partner close by. Nurses' Notes Day 1: Disheveled and wearing clothes that are soiled with food. Flat affect, disinterested in surroundings. Keeps eyes downcast and answers questions in a low voice volume. Day 2: Sitting in room. Refused to shower this morning. Consumed only a few bites of breakfast a

When analyzing cues, the nurse should identify that the findings of the client's statement of identify, their reaction to the visit from their adult children, and their statement of the desire to join their deceased partner indicate the client is experiencing prolonged grief disorder. These findings, combined with the client's self-care deficits, poor appetite, and depressed mood persisting 15 months following the death of their partner are unexpected findings and require additional evaluation and treatment.

A nurse is assessing an adolescent Nurses' Notes 12-year-old well-child exam Adolescent alert and pleasant. Makes good eye contact and has strong language skills. Adolescent reports participating in several extracurricular activities at school and that they are also active in their church youth group. Adolescent denies any current concerns regarding health, school, or relationships with peers and family. 13-year-old well-child exam Denies any change in health since last exam one year ago. Adolescent answers questions appropriately and appears well-groomed. During interview, adolescent noted to frequently blink rapidly and clear throat. Denies manifestations of respiratory tract infection or allergies. Adolescent reports starting menstrual cycle approximately 4 months ago, with irregular cycles occurring every 20 to 40 days. Also reports mild cramping with menstruation that is managed with over-the-counter analgesics. Flow Sheet 12-year-old well-child exam Height 155 cm (61 in) Weight 47.6 kg (105 lb) 13-year-old well-child exam Height 160 cm (63 in) Weight 49.9 kg (110 lb) Vital Signs 12-year-old well-child exam Heart rate 100/min Respiratory rate 22/min BP 96/58 mm Hg SaO2 98% on room

When analyzing cues, the nurse should identify that the frequent rapid blinking and clearing of the throat are unexpected findings that should be reported to the provider. These findings are manifestations of a tic disorder and require further evaluation. Tic disorders can start suddenly and worsen during times of stress. Most tic disorders resolve within a year from time of onset.

A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa. Vital Signs December 1: Heart rate 48/min Respiratory rate 24/min Blood pressure 78/52 mm Hg Temperature 35.6° C (96° F) SaO2 93% on room air December 15: Heart rate 55/min Respiratory rate 20/min Blood pressure 84/50 mm Hg Temperature 36° C (97° F) SaO2 96% on room air History and Physical December 1: Height 163 cm (64 in) Weight 34.5 kg (76 lb) BMI 13 Pale, cold extremities, dry skin, thinning hair Weak pulse Respirations slightly labored, chest clear Bowel sounds hypoactive x 4 quadrants Concentrated urine December 15: Height 163 cm (64 in) Weight 37.2 kg (82 lb) BMI 14.1 Pale, cold extremities, dry skin, thinning hair Pulses palpable Respirations even, unlabored, chest clear Bowel sounds active x 4 quadrants Clear yellow urine Laboratory Results December 1: Basic Metabolic Profile: Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) BUN 30 mg/dL (10 to 20 mg/dL) Sodium 128 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L) December 15: Basic Metabolic Profile: Creatinine 0.9 mg/dL (0.5 to 1.0 mg/dL) BUN 22 mg/dL (10 to 20 mg/dL) Sodium 130 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5

When evaluating outcomes, the nurse should identify that the findings of increased weight, improved respiratory assessment, and a creatinine level that is now within the expected reference range are indications of a therapeutic response to the treatment plan.

A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa. Vital Signs December 1: Heart rate 48/min Respiratory rate 24/min Blood pressure 78/52 mm Hg Temperature 35.6° C (96° F) SaO2 93% on room air December 15: Heart rate 55/min Respiratory rate 20/min Blood pressure 84/50 mm Hg Temperature 36° C (97° F) SaO2 96% on room air History and Physical December 1: Height 163 cm (64 in) Weight 34.5 kg (76 lb) BMI 13 Pale, cold extremities, dry skin, thinning hair Weak pulse Respirations slightly labored, chest clear Bowel sounds hypoactive x 4 quadrants Concentrated urine December 15: Height 163 cm (64 in) Weight 37.2 kg (82 lb) BMI 14.1 Pale, cold extremities, dry skin, thinning hair Pulses palpable Respirations even, unlabored, chest clear Bowel sounds active x 4 quadrants Clear yellow urine Laboratory Results December 1: Basic Metabolic Profile: Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) BUN 30 mg/dL (10 to 20 mg/dL) Sodium 128 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L) December 15: Basic Metabolic Profile: Creatinine 0.9 mg/dL (0.5 to 1.0 mg/dL) BUN 22 mg/dL (10 to 20 mg/dL) Sodium 130 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5

When evaluating outcomes, the nurse should identify that the findings of increased weight, improved respiratory assessment, and a creatinine level that is now within the expected reference range are indications of a therapeutic response to the treatment plan.

A nurse on a mental health unit is caring for a client. Nurse's Notes 1300: Client openly participated in group therapy and provided validating feedback to peers. Described a longstanding pattern of frequent changes in their life: changes in hobbies, employment, and in their friends. Reports a history of giving their best friends numerous gifts and constantly calling them every day, only to suddenly ignore and belittle them, followed by regret for doing so. Client also shared that they frequently feel "super nervous" and are restless for no known reason. Client reports that this anxiety makes sleeping and focusing on tasks difficult. 1530: The client approached the nurse's station and attempted to interrupt a staff member who was talking on the phone. After noticing the staff member has a hearing impairment, the client loudly yelled, "Are you deaf or something?" and walked to their room. A couple of minutes later, the client rushed back to the nurse's station with the appearance of panic and said to the staff member, "I'm sorry, I'm so sorry. Please don't hate me!" History and Physical Borderline personality disorder, diagnosed 2 years ago. History of non-suicidal self-injury, intermitt

When generating solutions while planning care for this client, the nurse should determine if the client is having thoughts of harming themselves or others. Clients who have borderline personality disorder often exhibit self-injurious behaviors, such as cutting or scratching. They also often experience suicidal ideation, even chronically, and have a higher risk for death by suicide. Feelings of hostility and anger are also common with this disorder, increasing the risk for violence toward others. The nurse should encourage the client to verbalize their feelings to diffuse frustration and other emotions. Clients who have borderline personality disorder experience emotional lability; therefore, verbalization of these emotions can decrease the impulsive behaviors often exhibited by clients who have this disorder. The nurse should establish consequences for unacceptable behavior such as manipulation and impulsivity, which are manifestations of this disorder. Clearly communicate expected behaviors and the subsequent consequences when unacceptable behavior occurs. The nurse should also provide clear boundaries for behaviors toward peers as clients who have this disorder can exhibit aggression and manipulation of others for their own benefit. The nurse should instruct the client on coping mechanisms and relaxation techniques. Clients who have borderline personality disorder also often have another mental illness, such as depression or anxiety disorder. The client verbalized feeling anxious and restless and that these feelings are disrupting their sleep and ability to focus. Therefore, identifying and practicing coping mechanisms and relaxation techniques are interventions that can decrease the client's anxiety.

A nurse is caring for a client who is dying. Nurses' Notes Day 1 1000: Client resting quietly in bed. Client's partner in bedside chair. Partner has been providing comfort measures and non-pharmacologic interventions. States that they feel overwhelmed at times when providing care and becomes very emotional when talking about the future. Day 2 1030: Client's partner overheard crying in the bathroom. States that the impending death is too much to bear right now and the decisions that must be made are exhausting. They are not sleeping well at night and their appetite is significantly decreased. Verbalizes feelings of anxiety. Hospice care arranged for client's upcoming discharge. Respite care discussed with the client's partner. Day 3 1300: Client alert and oriented x4. Client discharged to home with hospice care. Partner will be providing care to the client at home. A nurse is planning self-care education for the caregiver of a client who is dying. Which of the following recommendations should the nurse include? Select all that apply. Increase recommended daily caloric intake. Walk for at least 30 min each day outside. Limit leisure activities for the caregiver. Establish a sleep routine

When generating solutions, the nurse should encourage the caregiver to walk outside for 30 minutes each day and establish a routine of at least 7 hr of sleep per night. The nurse should identify that a self-care routine that includes daily physical exercise is recommended for caregivers to support their physical and mental well-being. Adults require 7 to 9 hours of sleep each night and getting adequate sleep can enhance the caregiver's emotional and physical health.

A nurse is caring for a client in an outpatient substance use disorder treatment facility. Nurses' Notes Nurses' Notes Week 1: 32-year-old client presents to treatment facility with 6-year history of stimulant use disorder. Client started using cocaine to help with energy needed to adapt to new job and newborn baby. Client recently completed detoxification treatment at an inpatient facility and is planning to continue treatment on an outpatient basis once weekly. Week 2: Participating in individual and group therapy activities. Engages with staff and other clients. Week 3: Showed up in soiled work clothes. Very talkative, restless, and constantly moving around. Overheard telling another client, "I have not had a BM yet today." During a coffee break after group therapy client announced, "Feel my arm, I think I have a fever, and my heart feels like it is racing." Pupils are noted to be dilated. Click to highlight the findings in the nurse's notes that require immediate follow-up. To deselect a finding, click on the finding again. Client started using cocaine to help with energy needed to adapt to new job and newborn baby. Client recently completed detoxification treatment at an inpatie

When recognizing cues, the nurse should identify that restlessness, increased psychomotor activity, increased alertness, elevated body temperature, tachycardia, and dilated pupils are manifestations of cocaine intoxication and should be addressed immediately. The recent completion of detoxification, wearing soiled work clothes, and lack of a BM today are not indicative of significant changes to the client's condition and do not suggest cocaine use.

A nurse in a mental health clinic is caring for a client who is grieving. Nurses' Notes 1000: Client presents to the mental health clinic and is tearful and angry. They recently experienced the loss of a child due to illness. Information provided to client about group therapy and individual therapy. 1100: Client is continuing to sob and states, "I can't go on living without my child." Current list of home medications reviewed. Client states they have not been taking the prescribed medication "because it will not help." 1300: Client spoke in group therapy session regarding feelings and prescribed treatment. Acknowledges the role of the therapist and expectations of support group, yet confides, "My anger and sadness are still very Medication Administration 1000: Sertraline 100 mg PO BID Vital Signs 1015: Temperature 36.8° C (98.4° F) Heart rate 85/min Respiratory rate 15/min BP 147/86 mm Hg Oxygen saturation 99% A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply. Statement regarding outlook on living. Statement related to feelings of sadness and anger. Knowledge of expectations durin

When recognizing cues, the nurse should identify that the client's statements about their outlook on living and their use of pharmacological treatment are the priority findings to address. The nurse should identify that safety is a priority and suicidal thoughts or expressions require immediate intervention. The nurse should also recognize that pharmacological treatment can help in relieving the symptoms of depression, anxiety, and post-traumatic stress that is related to grief. The client's statement indicates a lack of understanding of this treatment modality.

A nurse in a provider's office is caring for a client. Admission Assessment Day 1 1400: Client seen for annual physical. Client, age 56, no current health issues, lives at home and works full time. Family history of Alzheimer's disease Vital Signs Day 1 1405: Temperature 37.1° C (98.8° F) Blood pressure 110/80 mm Hg Heart rate 172/min Respiratory rate 16/min SaO2 98% on room air Provider Prescriptions Day 1 1445: Provide teaching on the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) The nurse is providing dietary teaching about the MIND diet to the client to promote cognitive function. Which of the following information should the nurse include in the teaching? (Select all that apply.) Eat fish three times per week. Substitute beans and lentils for meat at most meals. Limit or abstain from alcohol. Increase intake of berries. Use canola oil when cooking. Restrict intake of nuts.

When taking action and providing dietary teaching on the MIND diet, the nurse should include the use of olive oil for cooking, increasing intake of berries, limiting or abstaining from alcohol, eating fish once per week, replacing beans and lentils for meat for most meals, and eating nuts to promote cognitive function.

A hospice nurse is providing support to the partner of a client who is dying. Nurses' Notes 1300: Client appears asleep. Client's partner is in bedside chair. 1400: Crackles noted upon auscultation of bilateral lung fields. Head of bed elevated to facilitate drainage. 1500: Client's partner crying and holding the client's hand. Client exhibiting irregular respiratory rate with periods of apnea and hyperventilation noted. Vital Signs 1300: Temperature 38° C (100.4° F) Pulse rate 62/min Respiratory rate 14/min B/P 104/64 mm Hg Oxygen saturation 96% 1400: Temperature 37.9° C (100.3° F) Pulse rate 45/min Respiratory rate 12/min B/P 95/55 mm Hg Oxygen saturation 95% Which of the following actions should the nurse take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Nursing Action Indicated Nonessential Contraindicated Offer to remain in the room. Call the provider to get a prescription for the partner. Inform the partner that the client is not in any pain. Encourage the client's partner to express their sorrow. Encourage the client's partner to stay awake as long as the client is al

When taking action for the partner of a client who is dying, the nurse should anticipate offering to remain in the room with the client and partner and encouraging the partner to express their feelings of sorrow. The nurse should identify that the partner is experiencing anticipatory grief and providing a therapeutic presence can help create a safe environment for grieving. Encouraging the partner to express their thoughts and feelings is therapeutic and promotes acceptance and healing in the grieving process. The nurse should identify that calling the provider to request a prescription for the partner is nonessential. The partner is experiencing anticipatory grief and requesting a medication prescription will not decrease the feelings of loss the partner is experiencing. The nurse should identify that informing the partner the client is not in pain and encouraging the partner to remain awake as long as the client is alert are contraindicated interventions. The nurse should not provide false reassurance to the partner as this is nontherapeutic. The nurse should also encourage the partner to rest as needed, since grief can cause somatic manifestations, such as disturbances in sleep and appetite.

Nurses' Notes 0800: Client observed at breakfast wearing hospital scrubs with the bottom of the pants rolled up and shirt arranged like a halter top. Client sat for less than 5 min and consumed half a piece of toast. Client took the juice box when leaving the table. Observed consuming juice and then dropping the box on the counter. The client reports not sleeping for 2 days. 1300: Client arrived at group. Moved chairs into a cluster and found a seat in the middle. Talkative, interrupting others despite reminders to allow all members to take a turn. After 10 min, client stood, paced quickly around the day room, and eventually left the group. Observed client entering another client's room, yelling out, "Yoo-hoo! Are you here?" Redirected by staff out of room and led to day room. Invited to a one-on-one as an alternative to group. "Oh, I can't do that, I have a meeting with the mayor shortly." 1730: Client at nurse's desk and continuing to pace around the desk. Talking about the day, moving closer to nurse with each sentence. Offered to walk away from the nurse's desk. Client states, "You want to be alone with me." As client quickly walked to day room, they stated "Oh, I am feeling hot,"

When using Maslow's hierarchy of needs, the nurse determines that the priority finding is physical exhaustion because of the client's constant motion, risk for inadequate nutritional intake, and altered judgment when in a manic state. Because of the manic state, the nurse should encourage frequent rest periods throughout the day. Excessive physical activity can lead to exhaustion. The nurse should also decrease the environmental stimuli as much as possible. The client is prescribed lithium, and it is important for the client to maintain adequate fluid and sodium intake. The client has a lithium and sodium level that are within normal limits. The client is taking aripiprazole and neuroleptic malignant syndrome is a potential adverse effect of the antipsychotic medication, but the client has not manifestations of the syndrome.

A charge nurse is teaching a new nurse about medical aid in dying, which is legal in their state. The new nurse states, "I have very mixed feelings about medical aid in dying. Do I have to participate in the client care?" Which of the following statements should the charge nurse make? "Medical aid in dying is controversial. The goal is to support the client and prevent pain and suffering." "Medical aid in dying is consistent with the client's right for self-determination. Why should that be a concern for you?" "Being involved in medical aid in dying within this state is a part of providing client-centered care. You will need to participate." "As a nurse, your involvement in the medical aid in dying process is not required. You can object to participation based on personal beliefs."

"As a nurse, your involvement in the medical aid in dying process is not required. You can object to participation based on personal beliefs." CORRECT The American Nurses Association clearly indicates that nurses may refuse to participate in medical aid in dying for personal or religious reasons.

A nurse is caring for a client who is experiencing grief. Which of the follow client statements are consistent with a diagnosis of prolonged grief disorder (PGD)? "I need my job; I have not missed a day of work in 2 years." "My sibling died 14 months ago. Every day since then has been horrible." "Before, I would love going fishing, but not anymore." "Sometimes, I wish it was me who was killed, not my sibling." "I just miss them every day and want to talk with them one more time."

"Before, I would love going fishing, but not anymore" is correct. This statement expresses a loss of pleasure in activities once enjoyed, which is consistent with PGD ."Sometimes, I wish it was me who was killed, not my sibling" is correct. This statement expresses blame or guilt and an expression of distress, which is consistent with PGD ."I just miss them every day and want to talk with them one more time" is correct. This statement expresses yearning for the client and distress in the loss, which is consistent with PGD.

A nurse is teaching a client who was diagnosed with prolonged grief disorder about the importance of cognitive behavioral therapy (CBT). which of the following client statements indicates an understanding of the teaching? "Cognitive behavioral therapy will help me make funeral and burial arrangements for my partner." "Cognitive behavioral therapy will teach me about what happened during my partner's medical treatment." "Cognitive behavioral therapy will help me answer all my questions about why my partner died." "Cognitive behavioral therapy will help me figure out how to live with the loss of my partner."

"Cognitive behavioral therapy will help me figure out how to live with the loss of my partner." Professional therapy, such as cognitive behavioral therapy, will focus on the client learning to adapt to life without their loved one as well as working on guilt or other feelings of grief.

A nurse is discussing a trauma-informed approach to care with a peer. Which of the following statements by the nurse reflects an understanding of self-reflection? "I find letting go of what just happened and moving on the best way to survive as a nurse." "I use a checklist when I prepare for client-centered care so I do not miss any of the important details." "To keep clients safe and promote healing, it is important to intentionally consider my words and actions." "Sometimes after a shift on my drive home I realize I don't remember what I said."

"To keep clients safe and promote healing, it is important to intentionally consider my words and actions." This response indicates an understanding of self-reflection. Self-reflection is an important part of trauma-informed care, because effective communication with the client promotes an environment of safety, equity, and inclusion.

A nurse is caring for a client who has anorexia nervosa and expresses anxiety about the weight gain restoration program. Which of the following statements should the nurse make? "Why do you become so frightened about gaining weight?" "Everyone feels better after they have completed the program." "What are your feelings about the restoration process?" "You will need to accept that increasing weight is a natural part of the program."

"What are your feelings about the restoration process?" This question is therapeutic because it avoids referring to weight gain in a manner that might be distressing to a client who has anorexia nervosa. The use of the phrase "restoration process" is more sensitive to the client's feelings of fear about gaining weight.

A nurse is screening children and adolescents for exposure to adverse childhood experiences (ACEs). Which of the following clients is considered to have experienced an ACE? A 12-year-old who failed an algebra test A 7-year-old who has a parent who is in prison A 13-year-old who forgot their lunch at home A 6-year-old who says, "My mom is mean because I can't have a dog."

A 7-year-old who has a parent who is in prison Having a parent or another household member in prison is considered an adverse childhood experience.

A nurse on an inpatient unit is caring for a group of clients who have depression. When planning care, which of the following clients should the nurse see first? A client who was admitted 1 week ago with premenstrual dysphoric disorder A newly admitted client who has bipolar I disorder A client on day 2 of admission who has disruptive mood dysregulation disorder A client on day 3 of admission who has a history of dysthymic disorder

A newly admitted client who has bipolar I disorder The nurse should identify that clients who have bipolar disorder can have severe manifestations of both depressio

A nurse is reviewing their state board of nursing's information about substance use rehabilitation programs for nurses. Which of the following is a reason to enroll a nurse into an Alternative-to-Discipline program? A character flaw A crime A mistake A treatable disease

A treatable disease An alternative-to-discipline (ATD) program is one in which the nurse who has had a substance use disorder will not practice nursing for a designated time while being involved in a recovery program or undergoing treatment. These programs view diversion of drugs not as a crime but as a serious but treatable disease.

A nurse is caring for a client who is grieving and has experienced sleep disturbances, weight loss, and often feels angry and irritable. The client also states that they feel depressed. Which of the following assessments is the nurse's priority? Spiritual practices Cultural practices Ability to function Social support

Ability to function Analysis of cues suggest the client has manifestations of prolonged grief disorder (PGD). Further assessment is needed to determine client's ability to function on a daily basis. Client safety and ability to care for themselves is the priority action for creating a plan of care.

A nurse is preparing to care for a client who is experiencing complicated grief. Which of the following actions demonstrates grief-informed care? Support the privacy of the client and do not discuss the loss. Contact the provider for directions on how to proceed. Stand when speaking to the client with door of the room open. Acknowledge and recognize that the client has experienced a loss.

Acknowledge and recognize that the client has experienced a loss. The nurse should take a grief-informed approach to care, which includes acknowledging and recognizing that the client has experienced a loss.

A school nurse is reviewing teacher concerns regarding the recent behavior of a school-age child. Which of the following findings is an indication of toxic stress? Acting out in the classroom Smoking in the bathroom Falling asleep during class Reporting frequent headache or stomach pain Participating in the soccer team Having one best friend in the class

Acting out in the classroom is correct. Frequent behavioral problems can be a sign that a child is experiencing toxic stress due to the effect of trauma. Smoking in the bathroom is correct. Early initiation of smoking can be a sign that a child is experiencing toxic stress due to the effect of trauma. Falling asleep during class is correct. Sleep disturbance, which includes falling asleep during class, can be a sign that a child is experiencing toxic stress due to the effect of trauma. Reporting frequent headaches or stomach pain is correct. Frequent headaches or illness can be a sign that a child is experiencing toxic stress due to the effect of trauma.

Which of the following roles is important for a nurse to undertake while working with a client who has a communication disorder? Speech therapist Advocate Diagnostician Legal representative

Advocate The role of advocate is a significant nursing role which helps maintain client dignity while supporting the best interests of the client.

A community health nurse is preparing an educational activity on Alzheimer's disease. Which of the following risk factors should the nurse include as the greatest risk for this disease? Genetics Age History of Down syndrome Androgen deprivation therapy

Age The nurse should identify the greatest risk for Alzheimer's disease is age.

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following comorbidities should the nurse anticipate when reviewing the client's medical record? Anorexia nervosa Post-traumatic stress disorder Agoraphobia Delusional disorder

Anorexia nervosa The nurse should identify that anorexia nervosa is a comorbidity for cluster C personality disorder.

A nurse is caring for a client who has cancer and is terminally ill. The nurse should recognize that the client and their family might be experiencing which of the following types of grief? Anticipatory Traumatic Complicated Disenfranchised

Anticipatory Anticipatory grief might be experienced by clients and their families when a client has a terminal illness and is still alive.

A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take? Ask the client about the lethality of their plan. Reassure the client that everything is going to work out. Encourage the client to focus on the positive aspects of life. Allow the client time alone to self-reflect.

Ask the client about the lethality of their plan. The nurse should identify that clients who are having suicidal ideation should be assessed for plans they have made as well as the lethality of their plans. Asking the client about the lethality of their plans will allow the nurse to learn more about the client's plans. The nurse should notify the client's treatment team of the client's suicide lethality plans.

A nurse in a community health care clinic meets with a 14-month-old child whose older sibling has autism spectrum disorder (ASD). Which of the following actions should the nurse take? Assist the guardians in obtaining a neurological screening for the 14-month-old child. Refer the child to psychiatric services for medication therapy to prevent ASD. Reassure the guardians that they should not worry because ASD doesn't run in families. Tell the guardians they need to wait until the child is 2 or 3 years old before any screening will provide valid results.

Assist the guardians in obtaining a neurological screening for the 14-month-old child. The nurse's role includes advocating for early screening for neurodevelopmental disorders.

A nurse is providing an educational program about eating disorders to the local community. The nurse should include that which of the following groups has an increased risk for developing an eating disorder? Athletes Chefs Movie directors Musicians

Athletes Some of the high-risk groups correlated with eating disorders include models, dancers, and athletes, such as gymnasts, wrestlers, figure skaters, and horse jockeys.

The guardians of a school-aged child state that they run in circles in the classroom, interrupt others' conversations at home, and cannot focus when doing homework. The nurse should recognize that these behaviors can be indicative of which of the following disorders? Stereotypic movement disorder Attention-deficit/hyperactivity disorder (ADHD) Autism spectrum disorder (ASD) Dysgraphia

Attention-deficit/hyperactivity disorder (ADHD) ADHD is a neurological condition that impairs one's ability to listen, focus, and follow instructions. Individuals who have ADHD might be extremely active and impulsive which can negatively impact social interaction and academic performance.

A nurse is talking with a newly hired nurse. The newly hired nurse states, "I really thought that I would easily transition from school to work. I am just exhausted, and now I wonder if I should even be a nurse." This statement that the nurse is experiencing which of the following types of stress? Grief Burnout Trauma grief Anxiety

Burnout This is an example of burnout because the newly hired nurse is experiencing a sense of powerlessness in the current situation.

Which of the following statements is true about children who have learning disabilities? Children who have learning disabilities might excel in reading skills. Children who have learning disabilities have below-average intelligence. Children who have learning disabilities have average or above-average intelligence. Children who have learning disabilities might excel in listening skills.

Children who have learning disabilities have average or above-average intelligence. This statement is true.

A nurse is caring for an adolescent who has experienced abuse and neglect since early childhood. The nurse should understand that this is an example of which of the following types of trauma? Vicarious trauma Acute trauma Chronic trauma Historical trauma

Chronic trauma Chronic trauma refers to multiple and/or persistent traumatic events that a client experiences over time, including long-term abuse and neglect. This type of trauma could also include ongoing isolation, poverty, or hunger.

A nurse is planning care for several clients. The nurse knows that which of the following findings are common in clients who have dependent personality disorder? Clients are fearful of making decisions. Clients demonstrate erratic behaviors. Clients are dramatic. Clients easily express disagreement with others.

Clients are fearful of making decisions. Clients with dependent personality disorder are fearful of making their own decisions and will need support to build confidence in their own decision-making.

A nurse is caring for a client who has depression. Which of the following noninvasive treatments should the nurse recommend to the client? Cognitive behavioral therapy Deep-brain stimulation Vagal nerve stimulation Electroconvulsive therapy

Cognitive behavioral therapy The nurse should recommend cognitive behavioral therapy (CBT) as a non-invasive treatment for depression. CBT usually involves meeting with a trained therapist who empowers the client to change behavior by changing their thinking.

A nurse is precepting a newly hired nurse. The newly hired nurse asks, "Why is it important for me to attend a training on compassion fatigue and burnout?" Which of the following responses should the precepting nurse make? "Compassion fatigue can occur because nurses often experience trauma. We must learn to prioritize our self-care." "This is something that human resources requires. There has been a lot of patient feedback about care." "The patient experience must include compassionate nursing care." "This is a part of orientation, and you need complete all your required training during orientation."

Compassion fatigue can occur because nurses often experience trauma. We must learn to prioritize our self-care." Compassion fatigue (CF) can be experienced by nurses due to occupational stress and exposure to trauma, such as the death of clients. Education about CF and best practices, such as self-care practice, are important strategies to reduce CF.

A nurse is assessing a client who has been diagnosed with prolonged grief disorder (PGD). The nurse should identify which of the following findings as an indication that the client has developed separation distress? Intense sorrow and emotional pain Continuous yearning for the deceased person Preoccupation with the person who died Preoccupation with the circumstance of the death

Continuous yearning for the deceased person Separation distress is a significant post-loss condition and is an attachment state that is expressed by the client's yearning.

A nurse is planning care for a client who has dementia. The provider has prescribed massage therapy for the client. Which of the following should the nurse identify as the purpose for this treatment? Evoke memories Decrease depression Promote cognitive function Improve socialization skills

Decrease depression The nurse should identify that massage therapy along with medication can be effective in decreasing depression for a client who has dementia.

A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following? Confusion Delusions Inappropriate guilt Mania

Delusions The nurse should identify that clients who have depression may exhibit manifestations of delusions or hallucinations. These findings are characteristic of psychotic depression.

A nurse on an inpatient mental health unit is caring for a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect? Depersonalization Poor concentration Voice tremors Shakiness

Depersonalization Depersonalization is a manifestation of panic level anxiety.

Which of the following comorbidities would a nurse expect when caring for a client with Down syndrome? Tic disorder Developmental Coordination Disorder (DCD) Learning disorders Depression

Depression Individuals who have Down syndrome often have comorbid psychiatric conditions, including depression and anxiety

A nurse is monitoring a client who has been diagnosed with post-traumatic stress disorder (PTSD). The nurse recognizes that people diagnosed with PTSD may exhibit symptoms similar to which of the following mental health disorders? Depressive disorders Anxiety disorders Substance use disorder Dissociative disorders Anorexia nervosa Schizophrenia spectrum disorders

Depressive disorders is correct. People diagnosed with PTSD term-6may exhibit symptoms of depression or be diagnosed with a comorbidity of a depressive disorder. Anxiety disorders is correct. People diagnosed with PTSD may exhibit symptoms of anxiety or be diagnosed with a comorbidity of an anxiety disorder. Substance use disorder is correct. People diagnosed with PTSD may exhibit symptoms of substance use or be diagnosed with a comorbidity of substance use disorder. Dissociative disorders is correct. People diagnosed with PTSD may exhibit symptoms of dissociation or be diagnosed with a comorbidity of dissociative disorders.

A nurse is caring for a school-age child who witnessed a violent crime. Each time the child recalls the event, the details differ from prior recollections. Which of the following trauma-related symptoms is the child experiencing? Depersonalization Derealization Hypervigilance Dissociative amnesia

Dissociative amnesia This child is experiencing dissociative amnesia, which is a negative cognitive symptom resulting in an inability to recall important aspects of the traumatic event.

A nurse is preparing a presentation for newly hired nurses about self-care of the nurse. Which of the following examples of self-care routines should be included? Eating balanced and nutritious meals Exercising occasionally Taking time for relaxation Establishing healthy boundaries Taking a lunch break

Eating balanced and nutritious meals is correct. Self-care routines, such as eating balanced and nutritious meals, should be practiced at work and home to promote physical, psychological, emotional, and spiritual self-care. These focus on individual health and wellbeing. Taking time for relaxation is correct. Self-care routines are to include current practices at work and home regarding physical, psychological, emotional and spiritual self-care. These focus on individual health and wellbeing. Establishing healthy boundaries is correct. Healthy boundaries provides limits or rules within a nurse-client relationship which and helps protect the nurse's and client's person's health, self-esteem, and well-being. Taking a lunch break is correct. Self-care routines, such as taking a lunch break, should be practiced at work and home to promote physical, psychological, emotional, and spiritual self-care. These focus on individual health and wellbeing.

A nurse is meeting with a client who has been treated at a substance use disorder clinic for three months. The client has had two follow up appointments at the clinic since their first visit, has attended a community-based peer support group twice weekly, and has taken their prescribed medication as directed. The nurse is discussing the effectiveness of these interventions with the client. The nurse is completing which of the following phases of the nursing process? Analysis/diagnosis Evaluation Planning Implementation

Evaluation The question accurately describes the evaluation phase of the nursing process.

A nurse is developing a discharge plan for a client who is in a detoxification unit. The nurse should include which of the following in the client's relapse prevention plan? Limit partying with former friends to once weekly, lock up substances in the home, and turn over finances to another person. Find a support person or sponsor, identify triggers, and develop new coping skills. Isolate at home, take leave of absence from job, and limit social contacts. Solicit a support person to transport to meetings, live in the home with client, and prevent them from using the substance.

Find a support person or sponsor, identify triggers, and develop Relapse prevention plans include attending meetings regularly, having a support person or sponsor to talk with and be accountable to, identifying potential triggers to substance use, developing new coping skills instead of substances, and learning skills to regain abstinence if relapse occurs.

A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client? Have toys or drawing materials available for the child. Have the child carefully repeat the events of the trauma. Assess the child without their caregiver present. Focus on the physical domain of health.

Have toys or drawing materials available for the child. Children may require play or creative outlets such as toys or coloring to express thoughts and feelings. This is an appropriate strategy for assessing a child.

A nurse in an outpatient mental health clinic is discussing the development of anxiety-related disorders in children to a group of parents. The nurse should include that which of the following is an adverse childhood experience (ACE) that can contribute to the development of an anxiety disorder? Having a family with a strong social support system Having caregivers who have steady employment Having a physical disability Performing well in school

Having a physical disability Having a physical disability is an example of an adverse childhood experience and places the child at increased risk for developing an anxiety disorder.

A nurse is caring for a client who regularly uses methamphetamine and is experiencing blood vessel constriction and spasming. The nurse should identify that the client is at high risk for developing which of the following conditions? Heart disease and stroke Brain trauma and injury Bone loss and osteoporosis Liver and pancreatic disease

Heart disease and stroke This is correct. The blood vessels constrict and spasm with use of methamphetamine, which can contribute to the client's risk of developing heart disease. These clients may also be at risk for a stroke because of a significant rise in blood pressure.

A nurse is reviewing a client's medication administration record and notes a new prescription for tetrabenazine. The nurse should identify that this medication is prescribed to treat which of the following types of dementia? HIV infection Lewy body disease Vascular disease Huntington's disease

Huntington's disease The nurse should identify the only medication that is effective in treating Huntington's disease dementia is tetrabenazine.

A nurse is caring for a client who has dementia and observes that the client becomes stressed and requires assistance and monitoring when their family visits. When the family leaves the room, the client returns to baseline and the deficits are gone. Using the Functional Assessment Stage Tool, the nurse should identify that the client is in which of the following stages of Alzheimer's disease? Severe Incipient Moderate Mild

Incipient The nurse should identify that the client is in the incipient stage of Alzheimer's disease. In the incipient stage, the client requires assistance and monitoring when stressful events arise. After the stressful event, the client returns to baseline and the deficits are gone

A team of providers, nurses, social workers, and counselors work together to provide care for a client with a substance use disorder. Which of the following names describes this group of clinicians? Tactical team Interdisciplinary team Triage team Collaborative team

Interdisciplinary team This group of clinicians would be called an interdisciplinary team. There are many medical professionals that make up the interdisciplinary team, including a physician or nurse practitioner, nurses, and clinical support staff.

A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate for the client? Antipsychotic medications Dialectical behavior therapy Antidepressant medications Interpersonal therapy

Interpersonal therapy Interpersonal therapy works from a framework that the client's problems arise from issues of role definition and grief and will frame solutions in interpersonal terms. This therapy is useful for those with avoidant personality disorder who seek the approval of others and fear rejection.

A nurse is caring for a client who has anorexia nervosa. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Introduce coping strategies to reduce anxiety associated with eating. Summarize the goals that were met during treatment. Gather information about the client's "fear foods." Identify treatment goals related to the client's body image.

Introduce coping strategies to reduce anxiety associated with eating. The nurse should introduce coping strategies during the working phase of the nurse-client relationship.

A nurse is responding to a client diagnosed with acute trauma disorder following the sudden death of their child. The client is pacing, wringing their hands, and crying stating "I am just so angry!" The client's vital signs are heart rate 108/min, blood pressure 142/82 mm Hg, and respiratory rate 24/min with shallow respirations. Which of the following nursing actions should the nurse take? Keep hands where the client can see them. Acknowledge what the client is experiencing and willingness to help Ensure the client has adequate personal space. Touch the client to show compassion. Use humor and maintain a constant smile. Insist that the client calm down immediately.

Keep hands where the client can see them is correct. This action can nonverbally communicate support and empathy, as well as diminish any threatening nonverbal body language. Acknowledging what the client is experiencing and willingness to help is correct. This is an appropriate response as this provides therapeutic presences and suggests partnering toward a solution. Ensure the client has adequate personal space is correct. Staying at least an arm's length away from the client shows respect for their personal space and ensures safety for both the client and the staff.

A nurse is weighing a client who was recently admitted into the eating disorder program. Which of the following actions should the nurse take? Invite the client to predict their weight beforehand. Weigh the client each day after their evening meal. Demand that the client remove hidden objects from their clothing prior to being weighed. Monitor for any extra fluids the client may have consumed prior to being weighed.

Monitor for any extra fluids the client may have consumed prior to being weighed. The nurse should monitor the client's fluid consumption because they might attempt to fluid load prior to being weighed to manipulate the weight reading.

A nurse is caring for a client who recently gave birth. The nurse notices the newborn is displaying manifestations of opioid withdrawal. The nurse should recognize the newborn's manifestations as signs of which of the following conditions? Fetal alcohol syndrome Tolerance Substance use disorder Neonatal abstinence syndrome

Neonatal abstinence syndrome Opioid withdrawal in a newborn whose mother used opioids in pregnancy is known as neonatal abstinence syndrome.

A nurse is preparing for a home visit with a client whose partner recently died by suicide. Which of the following actions should the nurse take first when preparing to provide client-centered care? Review current provider prescriptions. Read the client's progress notes. Review the client's history. Perform self-reflection.

Perform self-reflection. Performing self-reflection allows the nurse to consider their own beliefs, values, personal losses or grief, and any bias they might have. This is an important first step in preparing for client-centered care.

A nurse in the clinic is assessing a postpartum client. The client states that they sleep all the time and are hearing voices telling them to harm their child. The nurse should identify that the client is likely experiencing which of the following? Postpartum depression Psychotic depression Premenstrual dysphoric disorder Bipolar disorder

Psychotic depression The nurse should identify that the client is exhibiting manifestations of depression with psychotic features, such as hallucinations.

A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client? Elevated heart rate Hypertension Tachypnea Pupillary dilation

Pupillary dilation Acute toxicity of opioids can result in hypoxia, which is a condition that results when too little oxygen reaches the brain. Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, and death.

A nurse is caring for a client who has autism spectrum disorder (ASD). Which of the following clinical manifestations should the nurse expect to observe? Making eye contact with peers Engaging in new activities Interacting with peers Repeating what others say

Repeating what others say Young children who have ASD often exhibit restricted, repetitive patterns of behavior, interests, or activities. This may include repeating the words and actions of others without reason or context.

Which of the following phases of Selye's General Adaptation Syndrome (GAS) reflects a nurse's ability to successfully perform duties during a prolonged period of stress lasting weeks to months without any indication of observable impairment? Exhaustion phase Adaptive phase Resistance phase Alarm phase

Resistance phase The resistance stage is defined as the phase where the body attempts to stabilize and repair itself following the alarm stage.

A nurse is caring for a client who has bulimia nervosa. Which of the following findings should the nurse expect? Lanugo Hyperkalemia Russell's sign Sunken parotid glands

Russell's sign Russell's sign is the presence of bruising and calluses on the knuckles of the hands due to self-induced vomiting. It can be an indicator of purging, which is a manifestation of bulimia nervosa.

A nurse is caring for a client who is experiencing mild depression and asks about herbal treatments. The nurse should identify that which of the following herbal treatments is used for depression? Black cohosh Ginseng St. John's Wort Ginkgo

St. John's Wort The nurse should explain to the client that St. John's Wort is an herbal supplement that is used as an alternate therapy for depression. The supplement should not be used in addition to an SSRI medication as this can lead to serotonin syndrome.

A nurse is caring for a client whose family has been reported missing. The client is visibly agitated; they are pacing and disregards the nurse's directives. The client loudly tells the nurse, "I want answers NOW". The nurse should identify that this client is in which of the following stages of crisis? Stage 3 Stage 2 Stage 1 Stage 4

Stage 3 This client is experiencing severe, escalating symptoms of crisis consistent with stage 3. The client's emotional capacity is diminished. They may be physically agitated and restless, and they may fixate on what is currently taking place.

A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the client states that they have been using cocaine at least once daily for the past 6 months. The nurse is collecting which of the following types of data from the client's account? Secondary Subjective Historical Objective

Subjective Subjective data is information that the client provides, such as self-reporting their level of substance use.

A nurse is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect? Lack of feelings of remorse Requiring frequent reassurance from others Suspiciousness of others Inflated sense of self

Suspiciousness of others Paranoid personality disorder is a cluster A disorder and is characterized by odd or bizarre behavior. The nurse should expect the client to exhibit suspiciousness, distrust, and possibly aggression if the client feels they are being mistreated by others.

A nurse is providing care to an older adult client. Which of the following screening tools should the nurse use to gather data for the client? Patient Health Questionnare-9 (PHQ-9) The Gerontological Personality Disorder Scale (GPS) Denver II Developmental Screening Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

The Gerontological Personality Disorder Scale (GPS) The GPS was developed to evaluate personality disorders in older adults and considers potential life-altering events that may have occurred for the client, which may affect reliability of the findings.

A charge nurse is observing a newly hired nurse provide grief-informed care for a client. Which of the following actions by the newly hired nurse requires follow-up by the charge nurse? The nurse determines the effect the death or loss has had on the client. The nurse acknowledges that the client experienced a death or loss. The nurse asks the client why they require care or assistance. The nurse advocates for the client to receive bereavement support.

The nurse asks the client why they require care or assistance. "Why" questions can be interpreted as judgmental and do not represent a grief-informed approach. A grief-informed approach focuses on what occurred (trauma or loss), where the trauma or loss took place, and how the trauma or loss affects the client's current condition or situation.

A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching? "My renal dysfunction could be the cause of my depressed mood." "My high blood pressure could be the cause of my depressed mood." "The stress from my new job could be the cause of my depressed mood." "My elevated heart rate could be the cause of my depressed mood."

The stress from my new job could be the cause of my depressed mood." The nurse should identify that the causes of mood disorders are an interplay of genetics, neurotransmitter dysfunction, brain dysfunction, neuroendocrine issues, environmental factors such as stress, and psychological factors such as sensitivity to stressors.

A nurse is caring for an adolescent client whose close friend recently died by suicide. The client tells the nurse, "I should have called back when they texted me. If I had been there, my friend would still be alive." Which of the following information should the nurse understand from this statement? This is an expression of delayed grief response, and the client is expressing their thoughts and feelings. This is an expression of a lack of self-compassion, and the client needs to focus on being kind to themselves. This is an expression of normal grief, and the client will respond well if they can just express their feelings. This is an expression of emotional pain, and the client needs to be closely monitored.

This is an expression of emotional pain, and the client needs to be closely monitored. This is emotional pain and feelings of guilt from a traumatic loss. It is important for this client to be closely monitored for safety.

A nurse is planning care for a client who has Alzheimer's disease and is in the terminal phase. Which of the following findings should the nurse expect? Unable to sit up Requires cueing to eat Speech degrades to a few words Needs assistance with finances

Unable to sit up CORRECT The nurse should identify that a client who is unable to sit up is in the terminal phase of Alzheimer's disease. Other manifestations can include the client not being unable to hold their head up or smile, requiring total care, and assuming the fetal position when lying dow

A nurse is admitting a client who has dementia related to a traumatic brain injury. Which ox Chorea Decreased CD4 counts Visual field cuts Shuffling gaitxs

Visual field cuts The nurse should identify that visual field cuts are a manifestation for a client who has experienced a traumatic brain injury. Other manifestations can include anosmia, hemiparesis, decreased cognitive function, and seizures.

A nurse on a mental health unit is caring for a client. History and Physical History of childhood emotional and physical neglect by parents. Mother has schizophrenia. Client diagnosed with paranoid personality disorder last year but has not followed outpatient treatment plan. Reports smoking 8 to 10 cigarettes a day and drinking vodka when available. Currently unemployed; was terminated from job after having altercations with other employees due to paranoid thoughts. Provider Prescriptions Pimozide 1 mg PO once daily Diazepam 5 mg PO every 6 hr PRN anxiety, agitation Nurses' Notes 0815: ED note: Client brought to emergency department (ED) by law enforcement after they responded to a call at a local grocery store. Per the police officer's report, the client was carrying a baseball bat and yelling at customers in the parking lot. When the officer approached the client, the client charged the officer and pushed them down. Client currently in handcuffs sitting in chair in exam room. Clothes dirty, client noted to be frequently scanning the room with their eyes. 0900: ED note: Handcuffs removed by police officer. Accompanied client to bathroom to void. Client now sitting on gurney in exam roo

When taking action for a client who has paranoid personality disorder, the nurse should place the client in a room near the nurse's station for close monitoring due to the client's increased risk for violence. The nurse should administer diazepam, a benzodiazepine, to reduce agitation and anxiety, which decreases the risk for aggression and violent behaviors. The nurse should also determine if the client is experiencing command hallucinations as this can be an emergent situation if the client hears voices telling them to harm themselves or others. The nurse should establish clear limits for the client's behavior, as well as consequences for unacceptable behavior.

A nurse is caring for a preschool-aged client who appears malnourished and dehydrated. Admission Assessment Nurses' Notes Admission Assessment Day 1 1400: Skin grayish in color and cold to touch. Decreased skin elasticity noted with prolonged capillary refill time of 3 seconds. Respiratory rate is rapid for client's age. Client is youngest of 3 siblings. Nurses' Notes Day 3 0900: Food tray noted across the room and not in reach of client. Caregiver eating takeout food from a local restaurant. Observed caregiver with client over last several days. No physical contact between child and caregiver. Caregiver interacts with child only when nurse requests assistance. Client reacts minimally to comforting measures implemented by nurse and turns away from nurse and caregiver when distressed. Caregiver states, "I am not a touchy feely sort of person, and my other kids have survived." Complete the following sentence by using the lists of options. The nurse recognizes the client is at highest risk for developing Select... as evidenced by the client's Select....

reactive attachment disorder reaction to comforting measures