ATI Learning Systems - Mental Health 2

A nurse is providing discharge teaching for a female client who has an anxiety disorder and a new prescription for lorazepam. Which of the following instructions should the nurse include in the teaching?

"this med must be discontinued gradually"

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

"this medication is an anti-psychotic that controls symptoms of schizophrenia." Antipsychotic medications, such as chlorpromazine, are thought to act directly on the dopamine receptors in the brain to prevent the reuptake of dopamine, thereby controlling psychotic manifestations.

A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for several months. Which of the following levels should the nurse recognize as a therapeutic lithium level?

1.2mEq/L range: 1.0-1.5 Clients taking lithium should drink six to eight glasses of water a day to maintain a normal state of hydration. Clients should also consume an adequate amount of sodium to prevent lithium toxicity.

A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

Head ache also: tachycardia, sweating, nausea, hand tremors, depression, irritability, vomiting This can occur 4 to 12 hr following cessation of alcohol use.

A nurse is assessing a client who has been taking thioridazine for several days. The client reports hand tremors, drooling, and rigid extremities. Which of the following actions should the nurse take?

administer benztropine; This client is experiencing extrapyramidal effects of thioridazine, which includes pseudoparkinsonism. Benztropine is a medication that counteracts these adverse effects. The nurse should notify the provider if extrapyramidal effects occur and obtain a prescription to alleviate the manifestations.

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates that the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take?

administer the med because it is within ranges

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

agoraphobia; fear and avoidance of places where escape might be difficult

A nurse is assessing< a client who has a psychotic disorder and a new prescription for haloperidol. The client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is the client likely experiencing?

akathisia akathisia is an extrapyramidal adverse effect characterized by the client's report of a sense of inner restlessness and by observable behaviors such as pacing, rocking forward and backward in a chair, and constant foot tapping.

A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors should the nurse identify as increasing the client's risk for depression?

being female

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client?

chicken nuggets, crackers, a cookie, cheese sticks. a nurse who is caring for a client who is in the manic phase of bipolar disorder should provide him with high-calorie finger foods that can be carried and are relatively easy to manipulate.

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as, "Me, see, bee, tree." The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia?

clang association The stringing and repeating of words together because of their rhyming sounds is called clang association. Clang association is a positive manifestation of schizophrenia.

A nurse is assessing a newly admitted client who has generalized anxiety disorder and states, "I drink alcohol to forget the pain." The client is exhibiting a maladaptive response to which of the following defense mechanisms?

compensation

A school nurse is caring for an adolescent client who has a history of a depressive episode 1 year ago. He appears withdrawn from social activities and his school performance is declining. Which of the following actions should the nurse take first

conduct a suicide risk assessment

A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited the day before. Which of the following cognitive impairments is the client demonstrating?

confabulation confabulation is filling in gaps in memory by fabrication.

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

demonstrating performance of hand hygiene as designated times

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?

determine the clients anxiety levels. before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client.

A nurse is assessing a client who has an anxiety disorder and is taking a benzodiazepine. For which of the following adverse effects should the nurse monitor the client?

dizziness other common adverse effects are drowsiness and sedation.

A nurse is providing discharge teaching for a client who has a new prescription for doxepin. Which of the following adverse effects should the nurse inform the client is associated with this medication?

drowsiness

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first?

explore what the voices are saying to the client

A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine The nurse should instruct the client that which of the following blood tests should be performed periodically?

glucose clients taking quetiapine are at risk for abnormal glucose metabolism, which can result in diabetes mellitus.

A nurse in the emergency department is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?

hyper vigilance - also : dilated pupils, hyper activity,

A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following statements by the client indicates an understanding of the teaching?

i should expect to feel the full effects of the medication after 2-4 weeks

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

impaired judgement

A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. Which of the following actions should the nurse take first?

instruct the client to take slow, deep breaths

A nurse is assessing a client who has been taking an antipsychotic medication for 6 years and the provider has started tapering off the dosage. The nurse should monitor the client for which of the following manifestations of tardive dyskinesia?

involuntary tongue protrusion; TD begins with face and mouth and then leads to larger muscle groups

A nurse is assessing a client who has schizophrenia. The client states, "I need to get my gummamoshu from by my house." The nurse recognizes this statement as an example of which of the following?

neologism neologism, an invented word which has no meaning to those around.

An emergency room nurse is assessing a client who has an anxiety disorder. The client is flushed, perspiring profusely, and is experiencing palpitations. The client begins to scream, "I am going to die! This is it! I am having a heart attack!" The nurse should determine the client's level of anxiety to be which of the following

panic

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment?

physical needs first!

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take when dealing with the client's ritualistic behaviors?

plan the pts schedule to allow time for ritualistic behaviors

A nurse in a mental health clinic is assessing a client who has a history of mania. Which of the following findings indicates that the client is experiencing a relapse?

pressured speech

A nurse is providing teaching to a client who has a new prescription for phenelzine. The nurse should teach the client that which of the following over-the-counter medications can cause a hypertensive crisis when taken concurrently with phenelzine?

pseudoephedrine Pseudoephedrine interacts with MAOI medications and is therefore contraindicated.

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

rapid fluctuations in LOC

A nurse is caring for a client who has obsessive-compulsive disorder. The client engages in repeated handwashing daily. Which of the following should the nurse recognize as the purpose of the client's behavior?

relieving anxiety

A nurse on an inpatient unit is assessing a client who has claustrophobia. The nurse determines the client's condition has improved when he can perform which of following tasks?

ride in an elevator

A nurse is caring for a client who has a severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take?

speak to the client in a calm voice

A nurse is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective?

the clients report techniques she uses to promote sleep

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

this med can affect your ability to drive or operate machinery

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

this medication can be habit forming. Diazepam is a benzodiazepine agent. All drugs in this category can cause physical dependence and are considered controlled substances.

A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the client's provider immediately?

urinary retention

A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. Which of the following statements should the nurse make?

we will assist you in making decisions