Psych ATI Ch 11-21

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Care during the continuation phase focuses on treating continued manifestations of MDD."

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?

"ECT is effective for clients who are experiencing severe mania."

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dyphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?

"I am aware that my PMDD causes me to have rapid mood swings."

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following is an appropriate response by the nurse?

"I am here to provide care and cannot accept this from you."

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?

"I am no one, and everyone is me."

A nurse in a long-term care facility is caring for a resident who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following is an appropriate response by the nurse?

"I am your nurse. Let's walk together to your room."

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"I can promote my client's sense of control by establishing a schedule."

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following client statements indicates understanding of the teaching?

"I may feel drowsy for a few weeks after starting this medication."

A nurse is caring for a client who has bulimia nervosa and who has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following is an appropriate response by the nurse?

"I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication?

"I will need to discontinue this medication slowly."

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?

"I'm scared that you're going to leave me."

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lbs. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing?

"Life isn't worth living if I gain weight."

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the highest priority to report to the provider?

"My mother is currently on furosemide for her congestive heart failure."

A nurse is caring for a client who is on lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements by the nurse is appropriate?

"Regular aspirin would be a better choice that ibuprofen."

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates a need for further teaching?

"She should participate in an Al-Anon group to help her recover."

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements by the nurse is appropriate?

"Tell me about how you are feeling right now"

A nurse is preparing to obtain a nursing diagnosis of anorexia nervosa. Which of the following questions are appropriate for the nurse to include in the assessment?

"What is your relationship like with your family?" "Would you describe your current eating habits?" "Can you discuss your feelings about your appearance?"

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements by the nurse are appropriate?

"When did you start hearing the voices?" "It must be scary to hear voices." "Are the voices telling you to hurt yourself"

A nurse is caring for a client who has Alzheimer's disease and is beginning to experience noticeable short-term memory loss. When discussing a new prescription for donepezil, the nurse should include which of the following in the teaching?

"You can expect the progression of cognitive decline to slow with donepezil."

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

"this medication increases the release of serotonin and norepinephrine."

A nurse is discussing routine follow-up needs for a client who has a new prescription for valproic acid. The nurse should inform the client of the need for routine monitoring of which of the following?

AST/ALT and LDH

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the nurse notes that the lithium blood level is 1.2 mEq/L. Which of the following is an appropriate action by the nurse?

Administer the next dose of lithium carbonate as scheduled.

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has clinical findings of depression. The client lives at home with her husband and two young children. She currently smokes and has a history of chronic asthma. The nurse should identify which of the following as risk factors for depression for this client?

Age of 35 years old Female gender History of chronic asthma Currently smokes

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take?

Ask the client, "Are you seeing something on the ceiling?"

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following?

Attempt to reduce anxiety

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this client, which of the following are expected findings?

Attempts to convince other clients to give him their belongings Blames others for his past and current problems

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms?

Auditory hallucination Use of clang associations Delusion of persecution Constantly waving arms

A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds his teeth during the night which causes pain in his mouth. The nurse should identify which of the following as possible measures to manage the client's bruxism?

Concurrent administration of buspirone Use of a mouth guard Changing to a different class of antianxiety medications

A charge nurse is preparing a staff education session on personality disorders. Which of the following should be included as personality characteristics associated with all of the personality disorders?

Difficulty in getting along with other members of a group Display of defense mechanisms when routines are changed Difficulty understanding why it is inappropriate to have a personal relationship with staff

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following should the nurse include in the teaching?

Difficulty sleeping can indicate a relapse Participating in psychotherapy can help prevent a relapse Anhedonia is a clinical manifestation of a depressive relapse

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?

Disulfiram

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following are expected findings?

Family report of personality changes Hallucinations Restlessness

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following is an expected finding?

Fine tremors of both hands Vomiting Restlessness

A nurse observes a client who is pacing and wringing his hands. The client states, "I don't know why, but I've worried every day for over a year that my son will die a horrible death." The nurse identifies that this finding is consistent with which of the following disorders?

Generalized anxiety disorder

A nurse is assessing a client 4 hr. after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as an indication of serotonin syndrome?

Hallucinations Diaphoresis Agitation

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following is an expected finding?

Hallucinations Recurring nightmares

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding?

Hypokalemia Slightly elevated body weight

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following is the priority nursing action?

Identify the client's level of orientation

A nurse on an acute care unit planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions is appropriate to include in the client's plan of care?

Implement one-to-one observation during meal times

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following is the priority nursing intervention?

Implement seizure precautions

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take?

Initiate one-to-one observation of the client

A nurse is making a home visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following are appropriate suggestions to decrease the client's risk for injury?

Install childproof door locks Place the client's mattress on the floor Install light fixtures above stairs

A nurse in an acute mental health facility is caring for a client who is experiencing a mixed episode of bipolar disorder. Which of the following is the priority nursing action?

Monitor the client for escalating behavior

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following is appropriate for the nurse to include in the plan of care?

Offer concise explanations Establish consistent limits Use a firm approach with communication

A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation?

Older adults are at a higher risk for substance use following retirement

A nurse is caring for a client who is taking phenelzine. For which of the following adverse effects should the nurse observe?

Orthostatic hypotension Headache

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following is the highest priority action by the nurse?

Placing the client on one-to-one observation

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following in the teaching?

Polyuria Muscle weakness

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's spouse, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following is an appropriate action by the nurse?

Provide information on resources for respite care.

A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following is appropriate for the nurse to include in the teaching?

Report confusion as potential indication of toxicity

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms?

Splitting

A nurse is caring for a client who is experiencing a panic attack. Which of the following is an appropriate nursing intervention?

Stay with the client, and remain quiet.

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the highest priority for the nurse to report to the provider?

The client had a motor vehicle crash last year and sustained a head injury

A nurse is interviewing a 25-ears old client who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect?

The presence of manifestations for at least 2 years.

A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following should the nurse include in the teaching?

Void just before taking the medication Wear sunglasses when outside Chew sugarless gum