RN Mental Health Online Practice 2023 B

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? a. "I put in extra hours at work so I won't think about drinking." b. "I know that wine is good for my heart, so that's why I drink some each evening." c. "I make up for my drinking by taking my partner on nice vacations." d. "I am able to go to work every day, so I don't have a problem."

"I am able to go to work every day, so I don't have a problem." By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder.

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? a. "Information regarding clients should remain confidential until after their death." b. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." c. "As long as client identity is disguised, their health information can be shared between professionals on the internet." d. "In the event a client threatens harm to others, medications can be administered without consent."

"In the event a client threatens harm to others, medications can be administered without consent." The charge nurse should inform the participants that medications can be administered without consent if a client threatens harm to others. The nurse should always protect the health and safety of their clients, even when a client's safety is threatened by another client.

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

14 mL

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

Assess the client for evidence of a perceptual disturbance. The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions.

A nurse on a mental health unit is caring for a recently admitted client. For each potential assessment finding, click to specify if it is a positive or negative symptom of schizophrenia. -Alogia -Clang associations -Catatonia -Absence of intonation in speech -Delusions of grandeur -Withdrawal from social activities

Delusions of grandeur, clang associations, and catatonia are consistent with positive symptoms of schizophrenia. Positive symptoms, the presence of symptoms that are not ordinarily present, include hallucinations, delusions, paranoia, and disorganized or bizarre thoughts, behaviors, or speech. Absence of intonation in speech, alogia, and withdrawal from social activities are consistent with negative symptoms of schizophrenia. Negative symptoms, or the absence of something that should be present, include lack of goal-directed behavior, decrease in participation in social activities, and a flat affect.

A nurse is caring for a client who has anorexia nervosa. A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? (Select all that apply.) -Blood pressure -BMI -Skin temperature -Sodium -Glucose -Peripheral edema -Heart rate -BUN -Potassium -Bowel movement

Heart rate is correct. Clients who have anorexia nervosa usually have bradycardia. The client's heart rate is now within the expected reference range. BMI is correct. Clients who have anorexia nervosa usually have a BMI of less than 17. The client's initial BMI indicates moderate anorexia nervosa while the current BMI indicates mild anorexia nervosa. Glucose is incorrect. The client's glucose level has remained within the expected reference range, which does not indicate an improvement in the client's condition. Potassium is correct. Clients who have anorexia nervosa usually have hypokalemia. The client's potassium level is now within the expected reference range. Skin temperature is correct. Clients who have anorexia nervosa usually have cool skin. After 2 weeks, the client's skin is warm, which indicates improvement. Sodium is correct. Clients who have anorexia nervosa can have hypernatremia related to dehydration. The client's sodium level is now within the expected reference range. Peripheral edema is incorrect. The client's peripheral edema remains unchanged, which does not indicate an improvement in the client's condition. Bowel movement is correct. The client's constipation has improved based on the increased frequency of their bowel movements. Blood pressure is incorrect. The client's blood pressure still indicates hypotension, which does not indicate an improvement in the client's condition. BUN is correct. Clients who have anorexia nervosa usually have an increased BUN. The client's BUN level is now within the expected reference range.

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa. Click to highlight the information in the client's medical record that indicate the client's condition is deteriorating. To deselect information, click on the information again. -QT prolongation -Exercise regimen -Hematemesis -Temperature -Laxative use -BMI

QT prolongation is correct. The finding of QT prolongation in the client's ECG during the second visit reveals cardiac complications of anorexia nervosa. Changes in electrolyte levels can shorten or prolong the QT interval. This is an indication that the client's condition is deteriorating. Exercise regimen is correct. The client's purchase of exercise equipment and working out twice a day is a new manifestation of anorexia nervosa. This is an indication that the client's condition is deteriorating. Hematemesis is correct. New onset of hematemesis might be caused by esophageal irritation or ulceration due to the increase in the frequency of induction of vomiting. Continued induction of vomiting can cause esophageal rupture. Therefore, hematemesis is an indication that the client's condition is deteriorating. Temperature is incorrect. The client's temperature has remained within the expected reference range. A decrease in body temperature with cool skin is an indication that the client's condition is deteriorating. Laxative use is incorrect. The client's cessation of the use of laxatives is an indication that the client's condition is improving. BMI is correct. The client's BMI decreased between visits, which indicates the client is continuing to lose weight. This is an indication that the client's condition is deteriorating.

A nurse on an inpatient psychiatric unit is caring for a client who is experiencing alcohol withdrawal. The nurse is evaluating the client after interventions for alcohol withdrawal syndrome have been implemented. Which of the following findings indicate a positive response to therapy? (Select all that apply.) -Respiratory rate -Unable to recall the trip to the facility -Blood pressure -Slept with minimal disruption for 8 hr -Withdrawn and quiet upon awakening -Tremors -Heart rate -Temperature

Slept with minimal disruption for 8 hr is correct. One of the major goals for a client who is experiencing alcohol withdrawal syndrome is sedation and rest. The client slept for 8 hr, indicating a positive response to therapy. Blood pressure is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's blood pressure has decreased from 164/82 mm Hg to 124/62 mm Hg, indicating a positive response to therapy. Withdrawn and quiet upon awakening is incorrect. These are manifestations of the client's major depressive disorder and can increase the risk for suicidal ideation. Temperature is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's temperature has decreased from a high of 39.1° C (102.4° F) to 38° C (100.4° F), indicating a positive response to therapy. Unable to recall the trip to the facility is incorrect. Memory blackouts are a manifestation of alcohol withdrawal syndrome. The client's memory remains impaired and unable to recall recent events. Heart rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's heart rate has dropped from 122/min to 95/min, indicating a positive response to therapy. Tremors is correct. Tremors are a manifestation of alcohol withdrawal syndrome. The client's decreased tremor activity is an indication of a positive response to therapy. Respiratory rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's respiratory rate has dropped from a high of 26/min to 22/min, indicating a positive response to therapy.

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? a. Shuffling gait b. Hypotension c. Decreased WBC count d. Blurred vision

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

A nurse on a mental health unit is admitting a client who has bipolar disorder. Complete the following sentence by using the list of options. The first action the nurse should take is to address the client's ______ due to the client's ______.

When prioritizing hypotheses, the nurse should identify the greatest risk to the client is cardiovascular injury due to constant psychomotor activity. The client is pacing, moving arms and hands around dramatically, and is unable to sit still. This can increase the client's blood pressure and heart rate, which can indicate unexpected cardiovascular findings.

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? a. Move the client to a room near the nurses' station. b. Limit visitors until the client is oriented to the environment. c. Tell the client that their partner is deceased. d. Talk with the client about activities they enjoyed with their partner.

d. Talk with the client about activities they enjoyed with their partner. Talking about positive experiences can help distract the client from their disorientation

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? a. "I will spend extra time at work to keep from feeling depressed." b. "I will talk about my feelings with a close friend." c. "I will be able to learn how to prevent my partner's attacks." d. "I will use meditation instead of taking my antidepressant."

b. "I will talk about my feelings with a close friend." Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? a. A school-age child who has bruises on the knees b. An older adult client who is bedbound and has a stage IV pressure ulcer c. An adolescent who has a vaginal candida infection d. A young adult who is pregnant and has a sprained ankle

b. An older adult client who is bedbound and has a stage IV pressure ulcer. A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a. Orient the client to person, place, and time. b. Assist the client with deep-breathing exercises. c. Calm the client by using therapeutic touch. d. Have the client sit alone in a quiet room.

b. Assist the client with deep-breathing exercises. Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching? a. "I will avoid social events until my partner has completed treatment." b. "It is important for me to focus my attention on my partner's addiction." c. "I will not take charge of my partner's work responsibilities." d. "I want my partner to promise to change addictive behaviors."

c. "I will not take charge of my partner's work responsibilities." The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? a. Male gender b. Hyperthyroidism c. Substance use disorder d. Being married

c. Substance use disorder The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? a. The client will take prescribed medications as scheduled. b. The client will express feelings of frustration. c. The client will refrain from self-mutilation. d. The client will participate in group therapy.

c. The client will refrain from self-mutilation. The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the client to refrain from self-mutilation.

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? a. "It will be better for you to keep busy to avoid thinking about your child's death." b. "You will complete the grieving process about a year after your child's death." c. "The grief process will start once your child actually dies." d. "It is not uncommon to feel angry toward yourself or others."

d. "It is not uncommon to feel angry toward yourself or others." Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.

A nurse in an emergency department is caring for an adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? a. "They work so hard at ballet. Will they still be able to perform?" b. "They're happier with their appearance now that they've lost some weight." c. "They told me they were tired, so I did their chores for them today." d. "They won't let me take the trash from their room. I'm concerned about what they have in there."

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

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? a. Offering self b. Use of silence c. Attention to body language d. Reflection of feelings

d. Attention to body language Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.

A nurse in the emergency department (ED) is admitting a client who was dropped off at the front door. For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major depressive disorder. Each finding may support more than one disease process. -Weight change -Respiratory rate -Level of consciousness -Nausea and vomiting -Mental status

Weight change is consistent with major depressive disorder. Clients who have major depressive disorder can experience significant weight loss. A 5% or greater loss in weight in a month is considered significant. Level of consciousness (LOC) is consistent with alcohol toxicity. Alcohol is a psychotropic drug and, when ingested at an excessive volume, can affect a client's mood, behavior, and consciousness. Nausea and vomiting is consistent with alcohol toxicity. A BAC of 150 mg/dL can result in nausea and vomiting. Mental status is consistent with alcohol toxicity and major depressive disorder. Alcohol is a psychotropic drug and can result in decreased thinking ability, impaired judgment, and slowed thinking when ingested. A client who has a history of major depressive disorder can display a diminished ability to think or concentrate and is often indecisive. Respiratory rate is consistent with alcohol toxicity. A client who has a BAC of 300 mg/dL can exhibit a decrease in body temperature, blood pressure, and respiratory rate.

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

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

A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event. The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? (Select all that apply.) -"You should seek help if you have thoughts of self-harm." -"It is uncommon for people who survived a traumatic event to experience spiritual distress." -"It is common for people who survived a traumatic event to experience feelings of anxiety." -"A support group might be helpful to you during this time." -"You will have minimal problems performing your daily self-care tasks."

"It is uncommon for people who survived a traumatic event to experience spiritual distress" is incorrect. Clients who have experienced a traumatic event can experience spiritual distress. "It is common for people who survived a traumatic event to experience feelings of anxiety" is correct. Clients who have experienced a traumatic event can demonstrate manifestations of severe anxiety and panic attacks, including impulsivity and regression. "A support group might be helpful to you during this time" is correct. The nurse should encourage the client to participate in a support group, which can provide emotional support for a client who has experienced a traumatic event. "You will have minimal problems performing your daily self-care tasks" is incorrect. Clients who have experienced a crisis can have difficulty meeting their basic needs and performing self-care tasks. The nurse might need to assist the client to perform ADLs. "You should seek help if you have thoughts of self-harm" is correct. The nurse should inform the client that they should seek help immediately if they experience thoughts of self-harm or suicidal ideation.

A nurse in the emergency department (ED) is caring for a client who has alcohol toxicity. For each of the provider's potential prescriptions, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. -Obtain an Alcohol Use Disorders Identification Test (AUDIT) -Administer an anti-anxiety medication. -Monitor vital signs every 30 minutes. -Obtain CT scan of the brain. -Wake the client every 30 minutes for neuro assessment. -Initiate IV access.

CT scan of brain is nonessential. Although a head injury can mimic manifestations of alcohol withdrawal delirium, there is no indication that the client has had a head injury and requires a CT scan. Monitor vital signs every 30 min is anticipated. Vital signs should be monitored frequently to continually assess the client for peripheral circulatory collapse that can occur with alcohol withdrawal. Obtain an Alcohol Use Disorders Identification Test (AUDIT) is nonessential. This screening tool is a self-reporting tool to assist a health care provider with gaining information, which can be used to develop a plan of care. This is not an appropriate prescription for the client at this time, as they are experiencing psychotic manifestations of acute alcohol withdrawal. Initiate IV access is anticipated. Treatment for alcohol withdrawal syndrome requires sedation to prevent seizure activity and circulatory collapse. This is best accomplished for the client via the IV route. Administer an anti-anxiety medication is anticipated. The client is displaying agitation and reporting hallucinations and therefore requires anti-anxiety medication. Wake the client every 30 min for neurological assessment is contraindicated. The treatment plan for this client should include sedation to encourage rest. The client does not require a neurological examination every 30 min.

A nurse is caring for a client who has alcohol use disorder. Complete the following sentence by using the list of options. The client is at greatest risk for ______ as evidenced by the client's ______. Dropdown 1: -Ineffective coping -Dehydration -Violent behavior Dropdown 2: -Agitation -Loss of appetite -Inability to perform simple tasks

Drop down 1: Ineffective coping is incorrect. The nurse should continue to monitor the client for ineffective coping and encourage the client to use coping techniques. However, this is not the greatest risk for this client. Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for this client. Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcohol, which is causing them increasing agitation. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury. Dropdown 2: Agitation is correct. The client is at greatest risk of engaging in violent behavior as evidenced by the client's agitation, which can be indicated by pacing, restlessness, staring, silence, rigid posture, and clenched jaw. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury. Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for the client. Loss of appetite is an expected finding for a client who is experiencing alcohol withdrawal. Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to perform simple tasks and encourage use of coping strategies. However, this is not the greatest risk for the client.

A nurse in the emergency department (ED) is reviewing prescriptions from the provider. Complete the following sentence by using the lists of options. The nurse should first ______ followed by ______. Dropdown 1: -Repeat the blood glucose level -Monitor vital signs every 30 minutes -Initiate suicide precautions Dropdown 2: -Initiating IV access -Administering diazepam -Administering acetaminophen

Dropdown 1: Initiate suicide precautions is correct. The greatest risk to this client is self-injury. Therefore, the first action the nurse should take is to initiate suicide precautions. The client has a history of self-injury and indicates that they have had recent thoughts of harming themselves. Repeat the blood glucose level is incorrect. Repeating the blood glucose level is important for monitoring the glycogen stores of the client. However, there is another action the nurse should take first. Monitor vital signs every 30 min is incorrect. The nurse should monitor the vital signs at least every 30 min. However, there is another action the nurse should take first. Dropdown 2: Administering acetaminophen is incorrect. Hyperthermia is a complication of alcohol withdrawal syndrome. The client's temperature has steadily risen and should be addressed and reduced. However, the nurse must initiate IV access before the medication can be administered. Administering diazepam is incorrect. Diazepam is used during alcohol withdrawal to allow the client to relax and rest. However, the nurse must initiate IV access before the medication can be administered. Initiating IV access is correct. The client has multiple manifestations of alcohol withdrawal syndrome. The primary treatment goal is to provide sedation and IV fluids. Therefore, the nurse must initiate the IV access before these medications can be administered.

A nurse in the emergency department (ED) is caring for a client who has alcohol toxicity. Complete the following sentence by choosing from the lists of options. The client is at risk for developing _____ as evidenced by the client's _____. Dropwdown 1: -Aspiration -Alcohol withdrawal syndrome -Respiratory distress Dropdown 2: -Mental status -Pulse oximetry -Heart rate

Dropdown 1: Respiratory distress is incorrect. The client has an oxygen saturation of 96%, which is within the expected reference range. The client's respiratory rate has improved from 11/min to 20/min, so the risk of respiratory distress has resolved. Alcohol withdrawal syndrome is correct. The client had clear evidence of alcohol toxicity, including a BAC of 340 mg/dL. There has been no further alcohol intake since admission to the facility, increasing the client's risk for developing alcohol withdrawal syndrome. Aspiration is incorrect. This client is no longer displaying risk factors for aspiration. Level of consciousness (LOC) is no longer depressed from the alcohol toxicity, and the client is no longer vomiting. Dropdown 2: Heart rate is incorrect. Upon awakening, the client's heart rate has increased to 90/min, which is still within the expected reference range of 60 to 100/min. Mental status is correct. A client who has had an abrupt cessation of alcohol intake will exhibit hand tremors and mental status changes, including agitation, irritability, and anxiety. These are all manifestations of alcohol withdrawal syndrome. Pulse oximetry is incorrect. This client's pulse oximetry is within the expected reference range and does not indicate respiratory distress.

A nurse in the emergency department (ED) is admitting a client who was dropped off at the front door. The nurse is assessing the client. Select the 5 findings that require follow-up. -Nausea and vomiting -GSC score -Respiratory rate -Oxygen saturation -Temperature -BAC -Level of consciousness (LOC) -Blood glucose level -WBC count

Nausea and vomiting is correct. For a client who has ingested alcohol, nausea and vomiting can be an indication of alcohol toxicity, which can result in an alteration in vital signs. Blood glucose level is incorrect. Hypoglycemia can mimic the manifestations of alcohol toxicity. However, this client's blood glucose level is 82 mg/dL, which is within the expected reference range. Temperature is correct. The client can experience a reduction of body temperature as a manifestation of alcohol toxicity. Level of consciousness (LOC) is correct. A client who has an altered LOC following alcohol ingestion might be experiencing alcohol toxicity. BAC is correct. A BAC of 340 mg/dL indicates alcohol toxicity. This value indicates a critical level. Respiratory rate is correct. A respiratory rate of 11/min is below the expected reference range and can indicate alcohol toxicity in the client. Oxygen saturation is incorrect. An oxygen saturation of 95% is within the expected reference range. GCS score is incorrect. The GCS can measure neurological impairment, which can mimic alcohol toxicity. The client has a score of 13, which indicates there is no neurological impairment. WBC count is incorrect. When assessing a client for alcohol toxicity, other health conditions should be considered. A WBC count of 7,400/mm3 is within the expected reference range and indicates there is no infection in the body.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? a. The client recently lost a grandparent in a motor vehicle crash. b. The client's town was hit by a tornado. c. The client's youngest child is leaving for college. d. The client is ambivalent about their upcoming retirement.

a. The client recently lost a grandparent in a motor vehicle crash. The client experiences a situational crisis when an unexpected event occurs.

A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness? a. "I am going to order a wheelchair for when I'm unable to walk." b. "I am going to stop paying my bills since I won't be around much longer." c. "I wish you would go take care of somebody who actually needs you." d. "I am sure I'll be able to continue to care for myself without help."

a. "I am going to order a wheelchair for when I'm unable to walk." The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates they have accepted the reality of their illness. This statement is an example of the acceptance, or final, stage of grief.

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? a. "It appears as though you would like to open the door." b. "You will feel more comfortable after you've been here for a while." c. "It is okay to not want to be here." d. "You really shouldn't be pushing on the door."

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

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? a. A 35-year-old client who has major depressive disorder b. A 50-year-old client who has a blood alcohol level of 80 mg/dL c. A 17-year-old client who lives with friends d. A 65-year-old client who just received a dose of morphine

a. A 35-year-old client who has major depressive disorder A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? a. Allow the client time to formulate an answer. b. Prompt the client to give a response. c. Move on to the next client. d. Offer the client a suggestion for a goal.

a. Allow the client time to formulate an answer. Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? a. Clang association b. Word salad c. Neologism d. Echolalia

a. Clang association The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have a similar sound.

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? a. Increased creatine phosphokinase (CPK) b. Increased low-density lipoproteins (LDL) c. Decreased fasting blood glucose d. Decreased aspartate aminotransferase (AST)

a. Increased creatine phosphokinase (CPK) An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? a. The client reports command hallucinations. b. The client is exhibiting echolalia. c. The client reports loss of motivation. d. The client is exhibiting blunted affect

a. The client reports command hallucinations. The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others.

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? a. Total body fat 8.7% b. Potassium 3.6 mEq/L (3.5 to 5 mEq/L) c. Temperature 36.1° C (96.9° F) d. Heart rate 54/min

a. Total body fat 8.7% The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider.

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? a. "You might notice an increase in saliva while taking this medication." b. "You might experience difficulties with sexual functioning while taking this medication." c. "You should expect an improvement in symptoms of depression in 3 to 4 days." d. "You may notice a temporary ringing in the ears when starting this medication."

b. "You might experience difficulties with sexual functioning while taking this medication." Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs.

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

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

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? a. Tell the client to talk less or risk being removed from the meeting. b. Ask group members to discuss their feelings about this client's monopolizing behavior. c. End the group meeting and take the client aside to discuss the disruptive behavior. d. Focus on other group members and ignore the client who is doing all the talking.

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

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? a. Have the client participate in a morning aerobics group. b. Encourage frequent rest periods throughout the day. c. Provide a distraction such as television at night. d. Offer the client hot chocolate at bedtime.

b. Encourage frequent rest periods throughout the day. A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? a. Include a liquid supplement with meals. b. Identify the client's trigger foods. c. Allow the client at least 1 hr for each meal. d. Weigh the client at bedtime each day.

b. Identify the client's trigger foods. The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? a. Sedation b. Rhinorrhea c. Bradycardia d. Hypothermia

b. Rhinorrhea The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? a. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. b. The client reports an inability to breathe easily. c. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL (74 to 106 mg/dL). d. The client reports having recently started smoking cigarettes.

b. The client reports an inability to breathe easily. Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations and should be reported to the provider.

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? a. Complete documentation about the client's status every hour while they are in restraints. b. Maintain the client in restraints for a minimum of 4 hr. c. Apply restraints when other means of managing the client's behavior have failed. d. Request that the provider assess the client within 8 hr of the application of restraints.

c. Apply restraints when other means of managing the client's behavior have failed. According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team? a. Calling family members b. Spending time alone c. Giving away possessions d. Excessive crying

c. Giving away possessions Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? a. Sore throat b. Photophobia c. Hand tremors d. Constipation

c. Hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? a. Raise the pitch of the voice when speaking to the client. b. Begin the interview by explaining the plan of care. c. Interview the client in a private setting. d. Ask the client to complete a detailed questionnaire.

c. Interview the client in a private setting. The nurse should interview clients in a private place when asking questions regarding client health.

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

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

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse? a. Schedule the client for group therapy sessions. b. Maintain consistent rules. c. Provide frequent high-calorie snacks. d. Avoid the use of value judgments.

c. Provide frequent high-calorie snacks. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? a. Controls anger outbursts to avoid being placed in seclusion. b. No longer exhibits a fear of social or public situations. c. Refrains from manipulating others to earn dining room privileges. d. Imitates the therapist's use of a relaxation technique.

c. Refrains from manipulating others to earn dining room privileges The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

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

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

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? a. Blurred vision b. Orthostatic hypotension c. Dry mouth d. Acute dystonia

d. Acute dystonia The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take? a. Tell the client that the voices do not really exist. b. Touch the client to help reduce feelings of anxiety. c. Instruct the client to go to a quiet room when the voices start talking. d. Ask the client what the voices are saying.

d. Ask the client what the voices are saying. It is important for the nurse to ask the client directly about the hallucinations to determine if the client or others are at risk for injury.

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Obtain the weight of a client who has bipolar disorder and is experiencing mania. b. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. c. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. d. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

d. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound.

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? a. Increased confusion b. Sleep disturbances c. Cluttered environment d. Inappropriate dress

d. Inappropriate dress Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? a. Advise the client to take frequent sips of water. b. Recommend that the client exercise regularly. c. Consult a dietitian for a calorie-controlled diet plan. d. Instruct the client to avoid driving during initial therapy.

d. Instruct the client to avoid driving during initial therapy. The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? a. Lansoprazole b. Naproxen c. Magnesium hydroxide d. Phenylephrine

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

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? a. Decrease distractions during meal times. b. Provide positive feedback when the child completes a task. c. Clearly identify consequences for unacceptable behavior. d. Remove unnecessary equipment from the child's surroundings.

d. Remove unnecessary equipment from the child's surroundings. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? a. Confront the staff member. b. Encourage the client to report the incident. c. Document the incident in the client's health record. d. Report the occurrence to the charge nurse.

d. Report the occurrence to the charge nurse. It is the responsibility of the charge nurse and the nurse manager to confront the staff member about the derogatory comments made to the client.