RN Mental Health ATI Practice

a nurse is assessing a client for risk factors for the development of depression. the nurse should identify that which of the following factors places the client at an increased risk for depression?

the client has COPD. rationale: The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.

a nurse in a clinic is assessing a client whose partner died 4 months ago. which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning." rationale: The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief.

a nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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

a nurse in a community health center is counseling a family of two parents and two children. which of the following statements by a family member indicates manipulative behavior?

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

a nurse is caring for an older adult client who beings to cry and states, "I knew God would punish me and I deserve this horrible sickness!" which of the following responses should the nurse make?

"Let's talk about what is upsetting you." rationale: The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

nurse is caring for a group of clients. which of the following findings should the nurse report?

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

a nurse on an acute mental health facility is receiving a change-of-shift report for four client. which of the following clients should the nurse assess first?

A client who is experiencing delusions of persecution rationale: The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first.

a nurse is preparing to administer prescribed clozapine to a client. which of the following client laboratory results should the nurse review prior to administering the clozapine.

Absolute neutrophil count rationale: The nurse should review the client's absolute neutrophil count (ANC) prior to giving clozapine. Clozapine can cause severe neutropenia. If the ANC is below 1,000/mm³ the medication may be discontinued.

a nurse is caring for a client who has a personality disorder. for each potential nursing intervention, click to specify potential intervention is anticipated, nonessential, or contraindicated for the client. exhibit 1: Nurses' Notes Day 1, 0700: Talkative, well-groomed. States they are "looking forward to divorcing partner number four" because they have "found my next partner."Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2, 1000​: Restless for past 2 hr, pacing from bedroom to dayroom and mumbling to self Argued with nurse this morning about attending group therapy sessionStaring at staff members with fists clenched exhibit 2: Diagnostic Results Day 1, 0730: Hematocrit 45% (37% to 47%) Hemoglobin 14.5 g/dL (12 to 16 g/dL) Fasting blood glucose 92 mg/dL (74 to 106 mg/dL) exhibit 3: Graphic Record ​ Day 1, 0715:​ Temperature 36.2°

Administer haloperidol 2 mg IM is anticipated. The client is agitated and displaying manifestations of aggression. Therefore, haloperidol is anticipated. Hold next dose of buspirone is contraindicated. The nurse should plan to administer buspirone to decrease the client's anxiety. Request change of diet to mechanical soft is nonessential. The nurse should plan to maintain the client's diet as prescribed. The client does not exhibit manifestations of difficulty swallowing or chewing. Request prescription for digoxin 1 mg IV bolus stat is contraindicated. The nurse should identify that the client's heart rate is within the expected reference range. Digoxin is contraindicated for this client. Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it" is anticipated. The nurse should use therapeutic communication to promote rapport and reduce the client's anxiety.

a nurse is assessing a client who has schizophrenia. which of the following findings should the nurse document as negative symptom of this disorder?

Anhedonia rationale: Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

a nurse is planning discharge teaching for a client who had severe schizoaffective disorder. the nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment rationale: Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

a nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. which of the following should the clients partner report to the provider?

B. inability to sleep rationale: During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.

a nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. the clients admission blood alcohol level was 325 mg/dL (0 to 50 mg/dL). which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96 mm Hg rationale: Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and a fever greater than 38.3° C (100.9° F). It is important for the nurse to rule out infection in the client who has a fever.

a nurse is caring for a client who has a personality disorder. the nurse is caring for the client, who is in seclusion and under mechanical restraints. for each potential assessment finding, click to specify if the finding indicates the clients condition has improved, not changed, or has declined.

Client attempts to bite nursing staff when offered water is an indication the client's condition has declined. The client is exhibiting worsening aggressive and violent behavior by attempting to bite nursing staff members. Client follows instructions of the nurse is an indication the client's condition has improved. The client is exhibiting control over their behavior and is able to follow instructions. Client is silent and glaring at staff is an indication the client's condition has not changed. The client is still exhibiting agitation and nonverbal aggressive behaviors. Client verbalizes precipitating factors to violent outburst is an indication the client's condition has improved. The client is able to verbalize and identify factors that contributed to the violent behavior.

a nurse is caring for a newly admitted client. for each potential assessment finding, click to specify if the finding is consistent with positive or negative symptoms of schizophrenia. exhibit 1: Vital Signs 0800: Blood pressure 110/78 mm HgHeart rate 76/minRespiratory rate 18/minTemperature 37° C (98.6° F) 1200: Blood pressure 116/80 mm HgHeart rate 88/minRespiratory rate 20/minTemperature 38° C (100.4° F) exhibit 2: Medical History Client admitted following episodes of hallucinations and delusions, according to family member. Outpatient treatment has not been effective. Client has been unable to maintain their job. Friends state the client has been acting "weird." Family members have noticed the client no longer maintains a clean and neat appearance, which is unusual for them. exhibit 3: Nurses' Notes 0800: Client oriented to unit and introduced to staff. Client is quiet and withdrawn. Mumbles to sel

Delusions of grandeur, clang associations, and catatonia are potential assessment findings of positive symptoms of schizophrenia. Other positive symptoms include hallucinations, paranoia, and disorganized/bizarr`e thoughts, behaviors, or speech. Alogia and withdrawal from social activities are potential assessment findings of negative symptoms of schizophrenia. Other negative symptoms include lack of goal-directed behavior, social discomfort, and the inability to enjoy activities.

a nurse is planning discharge teaching with a family member of a client who has new diagnosis of depression. which of the following information about relapse should the nurse include?

Early identification of changes, such as decreased social involvement, is important. rationale: Decreased social involvement is a manifestation of depression, and early identification of findings can lead to early intervention.

a nurse is assessing a client who has borderline personality disorder. which of the following findings should the nurse expect?

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

a nurse in a mental health facility is caring for a client who requires the use of restraints. which of the following actions should the nurse take when caring for the client?

Ensure a staff member checks on the client every 15 min. rationale: When caring for a client who is in restraints, the nurse should assess the client's needs for hydration and elimination, and monitor the circulation in the extremities every 15 min.

a nurse in an inpatient mental health facility is caring for a client. the client begins pacing with their fists clenched and is verbally abusing the staff. which of the following actions should the nurse take?

Ensure security personnel are available in the background to assist if the client's behavior escalates. rationale: The client is exhibiting manifestations of anger and agitation that often precede a violent event. While the nurse should attempt to de-escalate the situation, safety measures should be in place. The nurse should verify that assistance is available if the client becomes violent. Security should be kept out of the client's line of sight until they are needed to avoid escalating the situation.

a nurse is planning prevention strategies for partner violence in the community. which of the following strategies should the nurse include as a method of secondary prevention?

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

a nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation. rationale: The nurse should gather supplies for endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.

a nurse is education the parent of a child who has a new diagnosis of autism spectrum disorder. which of the following manifestations of this disorder should the nurse include in the teaching?

Language delay rationale: The nurse should identify that language delays are a manifestation of autism spectrum disorder.

a nurse is caring for a client who has a personality disorder. the nurse is caring for the client . which of the following actions should the nurse take? select all that apply.

Maintain continuous observation of the client while in restraints is correct. The nurse should ensure a staff member remains with the client continuously while the client is in restraints. Conduct debriefing with the client and other staff is correct. The nurse should conduct debriefing with other staff members to indicate the necessity of the intervention and to ensure that quality care was provided. The nurse should conduct a debriefing with the client to discuss their thoughts about what contributed to the intervention and strategies for crisis prevention in the future.

a client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. the client who has depression reports to the nurse, "my roommate never sleeps and keeps me up, too." which of the following actions should the nurse tae?

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

a nurse is planning care for a client who has made repeated physical threats toward others on the unit. although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. which of the following ethical principles should the nurse apply in this situation?

Nonmaleficence rationale: It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit.

a nurse is caring for an older adult client who is experiencing delirium. which of the following interventions should the nurse include in the clients plan of care?

Permit the client to perform daily rituals to decrease anxiety. rationale: The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

a nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli. rationale: The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

a nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. which of the following strategies should the nurse use when communicating with this client?

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

a nurse on a mental health unit is caring for a group of clients. which of the following actions by the nurse is an example of ethical principle of justice?

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

A nurse is caring for a client who has a personality disorder. select the 6 findings in the clients medical record that are manifestations of the clients diagnosed personality disorder. exhibit 1: Graphic Record Day 1, 0715​: Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg exhibit: History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. exhibit 3: Provider Prescriptions Day 1, admission order: Regular

Stealing money from family to cover credit card charges is correct. The nurse should identify that stealing money is an impulsive behavior, which is a manifestation of borderline personality disorder. Anxious if left alone is correct. The nurse should identify that the client's anxiety about being left alone is due to fear of separation, which is a manifestation of borderline personality disorder. Hypersexualization is correct. The nurse should identify that hypersexualization is an impulsive, self-damaging behavior, which is a manifestation of borderline personality disorder. Married multiple times is correct. The nurse should identify that unstable romantic relationships are a manifestation of borderline personality disorder. Incidences of self-injury is correct. The nurse should identify that self-injury is a manifestation of borderline personality disorder. Self-destructive behaviors, such as cutting, are common with this disorder. Physical altercations is correct. The nurse should identify that engaging in physical altercations is a manifestation of borderline personality disorder.

a nurse is caring for client who has a personality disorder. for each potential providers prescription, click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder. each therapy can support more than one disease process. exhibit 1: History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years exhibit 2: Provider Prescriptions Day 1, admission order: Regular diet Activity as toleratedObse

Systematic desensitization is an expected therapy for obsessive compulsive disorder. This therapy provides relaxation techniques to address a client's fears. Validation therapy is an expected therapy for dementia. This therapy provides reorientation and validation for clients who experience a misperception of reality. Dialectical behavior therapy is an expected therapy for borderline personality disorder. This therapy provides cognitive and behavioral techniques for clients who are suicidal and have borderline personality disorder. Donepezil 5 mg PO daily is an expected therapy for dementia. This therapy is a cholinesterase inhibitor used to treat cognitive impairment. Fluoxetine 20 mg PO daily is an expected therapy for obsessive compulsive disorder and borderline personality disorder. This therapy is an SSRI used to reduce self-injurious behavior and decreases repetitive behavior.

while observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. which of the following behaviors is consistent with this condition>

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

A nurse is caring for a client who has impaired cognition. A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client. exhibit 1 Medical History Day 1, 0800: Client treated for UTI 8 months ago. Day 3, 0830: Client fell getting out of bed to go to the bathroom last night. Client sustained bruise to the left knee; no further injuries noted. Exhibit 2 Vital Signs Day 1, 0800: Temperature 36.9° C (98.4° F)Heart rate 92/minRespiratory rate 26/minBlood pressure 132/80 mm Hg Day 3, 0830: Temperature 37.3° C (99.1° F)Heart rate 106/minRespiratory rate 32/minBlood pressure 144/86 mm Hg Exhibit 3 Nurses' Notes Day 1, 0800: Client is able to assist with self-care. Client is easily startled by sudden changes and loud noises. Day 3, 0830: Client has wandered into oth

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

A nurse is caring for a client who has impaired cognition. a nurse is updating the clients plan of care. for each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client. exhibit 1 Medical History Day 1, 0800: Client treated for UTI 8 months ago. Day 3, 0830: Client fell getting out of bed to go to the bathroom last night. Client sustained bruise to the left knee; no further injuries noted. exhibit 2 Vital Signs Day 1, 0800: Temperature 36.9° C (98.4° F)Heart rate 92/min Respiratory rate 26/minBlood pressure 132/80 mm Hg Day 3, 0830: Temperature 37.3° C (99.1° F)Heart rate 106/min Respiratory rate 32/minBlood pressure 144/86 mm Hg exhibit 3: Nurses' Notes Day 1, 0800: Client is able to assist with self-care. Client is easily startled by sudden changes and loud noises. Day 3, 0830: Client has wandered into

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

nurse is caring for a client who has panic disorder. click to highlight findings in the medical record that indicate maladaptive use of defense mechanisms. exhibit 1: Medication Administration Record​ 0900:Fluoxetine 40 mg PO daily exhibit 2: Nurses' Notes 0900: Engaged with other clients. Consumed 90% of breakfast. Eager to participate in group therapy and is looking forward to group exercise class later this afternoon. 1400: Returned from exercise class in agitated state. According to other clients, the instructor had to tell the client to stop interrupting during the class. Client tells the nurse, "That exercise instructor was one of my favorite people here. We had so much in common. But now I know their true nature. She's evil!

When recognizing cues, the nurse should identify the client returning from exercise and being in an agitated state is the client demonstrating the maladaptive use of a deference mechanism. The nurse should also identify when the client tells them that the exercise instructor was one of their favorite people and had so much in common, but no one sees their true nature and that she is evil is the client demonstrating the maladaptive use of splitting. Splitting is the inability to combine positive qualities of a person into a unified likeness.

a nurse on a mental health unit is caring for a client who has schizophrenia. after reviewing the clients medical record, the nurse should notify the provider of which of the following findings? select the 5 unexpected findings that require notification of the provider. exhibit 1: Nurses' Notes 1200:​ Female client diagnosed with schizophrenia approximately 2 years ago after experiencing psychosis. Client has taken chlorpromazine and loxapine with minimal improvement in positive and negative symptoms. Client attends a local community college and works at a grocery store. exhibit 2: Vital Signs 0800:​ Blood pressure 112/66 mm HgHeart rate 88/minRespiratory rate 16/minTemperature 37.7° C (99.9° F)Oxygen saturation 98% on room air ​ 1200:​ Bloor pressure 104/60 mm HgHeart rate 106/minRespiratory rate 20/minTemperature 38.3° C (100.9° F)Oxygen saturation 97% on room air exhibit 3: Diagnostic Results 0

When taking actions, the nurse should identify an elevated temperature, hypoactive bowel sounds, a decreased ANC level, myalgia along with an increased heart rate can be adverse effects of the medication clozapine. Therefore, the nurse should report these findings to the client's provider.

A nurse is caring for a client who has posttraumatic stress disorder and a new prescription for sertraline. A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication? select al that apply. exhibit 1: Vital Signs Day 1, 0830: Temperature 36.6° C (97.9° F)Heart rate 92/minRespiratory rate 22/minBlood pressure 120/70 mm HgDay 3, 1000: Temperature 38.7° C (101.7° F)Heart rate 98/minRespiratory rate 24/min Blood pressure 140/86 mm Hg exhibit 2: Diagnostic Results Day 1, 0830: Sodium 138 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 4.5 mEq/L) Glucose 88 mg/dL (74 to 106 mg/dL) Day 4, 1000: Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 4.0 mEq/L (3.5 to 4.5 mEq/L) Glucose 77 mg/dL (74 to 106 mg/dL exhibit 3: Nurses' Notes Day 1, 0830: • Client is requesting a room at

When taking actions, the nurse should identify that an increased temperature, decreased sodium level, diaphoresis, insomnia, headache, and elevated blood pressure can be adverse effects of the medication sertraline. Therefore, the nurse should report these findings to the provider.

a nurse is planning care for a client who has depression and has made frequent suicide attempts. which of the following statements indicates the client has a decreased risk for suicide?

a. "I'm relieved now that my financial affairs are in order." b. "it is easier to talk about my feelings now." c. "suddenly i have enough energy to do anything I want" d. "thank you for always taking such good care of me" b. "it is easier to talk about my feelings now." rationale: when clients express their feelinds, this indicates a positive treatment outcome.

a nurse is admitting a client who has anorexia nervosa and is at 60% of their ideal body weight. which of the following interventions should the nurse include in the plan of care?

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

The client is seeking acceptance by the nurse.

a. Promote the use of music to compete with the client's auditory hallucinations. b. Inform the client that the auditory hallucinations are not real. c.Avoid asking the client if they are experiencing auditory hallucinations. d.Instruct the client on the use of voice recognition regarding the auditory hallucinations. a. Promote the use of music to compete with the client's auditory hallucinations. rationale: Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level.

a nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. which of the following interventions should the nurse include in the plan?

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

during a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. which of the following assumptions should the nurse make based on the client nonverbal behaviors?

a. The client is interested in what the nurse is saying. rationale: The client's posture and eye contact demonstrate an interest in the interview and what the nurse is saying.

a nurse is caring for a male client who has schizophrenia and is taking clozapine. which of the following client findings should the nurse identify as a contraindication for receiving clozapine?

a. WBC count 2,500/mm3 (5,000 to 10,000/mm3) b. Hgb 11.5 mg/dL (14 to 18 g/dL) c. alogia d. client reports having a dry mouth a. WBC count 2,500/mm3 (5,000 to 10,000/mm3) rationale: Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm³ as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

a nurse is caring for a group of clients. which of the following findings should the nurse report?

a. a client who is taking clozapine and has a WBC count of 7,500/mm3 (5,000 to 10,000/mm3) b. a client who is taking lamotrigine and has developed a rash. c. A client who is taking valproate and has a platelet count of 200,000/mm3 (150,000 to 400,000/mm3) d. A client who is taking lithium and has increased thirst b. a client who is taking lamotrigine and has developed a rash. rationale: lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. the nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately.

during a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

a. client is interested in what the nurse is saying. b. The client is attempting to manipulate the nurse. c. The client is physically attracted to the nurse. d. The client is seeking acceptance by the nurse. a. the client is interested in what the nurse is saying. rationale: the clients posture and eye contact demonstrate an interest in the interview and what the nurse is saying.

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)?

a. clinging behaviors directed toward a teacher b. increase time spent sleeping c. intense focus on school work d. lack of interest in an upcoming holiday D. lack of interest in an upcoming holiday rationale: the child who has PTSD will have negative moods an difficulty remembering aspects of the traumatic event. the child also have loss interest or lack of participation in significant activities and event such as holidays.

a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. to establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

a. inform the client that this admission is confidential. rationale: According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.

a nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members?

b. guided imagery rationale: Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder.

a nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. which of the following information should the nurse include in the teaching?

b. the client should obtain a sponsor before discharge for an increase chance of recovery. rationale: The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program.

a nurse is caring for a group of clients. for which of the following situations should the nurse complete an incident report?

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

a nurse is talking wit ha group of parents who have recently experienced the death of a child. which of the following actions should the nurse take?

c. Suggest forming a weekly support group for parents who have experienced the death of a child. rationale:Support groups are a positive resource in the process of recovery for parents following the death of a child.

a nurse on a mental health unit observes a client who has acute mania hit another client. which of the following actions should the nurse take first?

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

a nurse iin a providers office is collecting a health history from a guardian of a school age child who has been taking atomoxetine. which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

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

a nurse is caring for a group of clients. which of the following findings is the nurse required to report?

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

a nurse in a community health center is teaching families of clients who have post-traumatic stress disorder about expected clinical manifestations. which of the following manifestations should the nurse include?

c.Experiences feelings of isolation rationale: The nurse should expect clients who have PTSD to feel estranged and detached from others.

a nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). which of the following actions should the nurse include in the plan?

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

a nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. which of the following assessment findings support the nurses suspicion of delirium?

d. easily distracted. rationale: Extreme distractibility is a hallmark manifestation of delirium.

a nurse is planning care for a client who has generalized anxiety disorder. at which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

d. mild rationale: The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.

a nurse is assessing a client who recently used cocaine. which of the following findings should the nurse expect?

hypertension rationale: Cocaine is a stimulant that increases blood pressure.

a nurse is planning care for a client who has bipolar disorder and is experiencing mania. which of the following interventions should the nurse include in the plan of care?

offer the client high-calorie finger foods frequently. rationale: The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration.

a nurse is caring for a child who is taking methylphenidate. the nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?

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

a nurse is caring for a client who has a personality disorder. complete the following sentence by using the lists of options. exhibit 1: History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. exhibit 2: Provider Prescriptions Day 1, admission order: Regular diet Activity as toleratedObserve closely for self-injury or violence toward othersBuspirone 7.5 mg PO twice a day Haloperidol 2 mg IM every 3 hr PRN severe agitation Bacitracin ointment 0.25 to 0.5 in

the client is at risk for developing violent behavior as evidenced by the client's increased agitation

A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a selegiline 12 mg transdermal patch once daily. complete the following sentence by using the lists of options. exhibit 1: Nurses' Notes Tuesday: Client diagnosed with major depressive disorder 15 years ago. Visits clinic twice a week for outpatient group therapy with social worker and follow-up with nurse. Client actively participates in therapy. Acknowledges that relationship with family members has improved and there are fewer verbal altercations. Thursday: Client presents with irritability, diaphoresis, and severe headache, and states, "I am really feeling bad. My heart is pounding." Was excited to share they had met a friend for lunch before coming to the clinic. "Maybe it's something I ate, but we both had the same thing - corned beef sandwich with Swiss cheese. Do you think it is food poisoning?" ​ exhibit 2: Vital

the client is at risk of developing hypertensive crisis due to consuming foods high in tyramine