ATI Mental Health Practice 2016 A

A nurse is caring for a client who is experiencing alcohol withdrawal. The client has a heart rate of 110/min, blood pressure of 170/96 mm Hg, and temperature of 38.9 degrees Celsius( 102 degrees Fahrenheit). Client history and physical include that the client states he consumed alcohol 12 hours prior to admission and the client has a 2 pack/day smoking history. Client progress notes include bilateral tremors of the hands and finger, emesis of 30 mL bile-colored fluid, restlessness, unable to sit still, diaphoresis, and flushed skin. Which of the following medications should the nurse administer first? A. Diazepam 5 mg IV bolus B. Clonidine 0.1 mg transdermal patch C. Naltrexone 380 mg IM D. Bupropion 150 mg PO

A. Diazepam 5 mg IV bolus The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine. A. WBC 2500/mm3 B. Hbg 11.5 mg/dL C. Platelets 150,000/mm3 D. RBC 3.5 million/mm3

A. WBC 2500/mm3 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count below 3000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

The 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." When clients express their feelings, this indicates a positive treatment outcome.

A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the client's ability to cope with this situation? A. "Don't you think you'll get through this in time?" B. "To whom do you talk when you feel overwhelmed?" C. "Have you thought about rebuilding your home on the same site?" D. "Would you like me to find a therapist for you to speak with?"

B. "To whom do you talk when you feel overwhelmed?" By asking this question, the nurse is assessing the client's support systems, which is an important factor in the client's ability to cope with the situation.

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 reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? A. A client who has a fasting blood sugar of 80 mg/dL B. A client who has a sodium level of 128 mEq/L C. A client who has a BUN of 18 mg/dL D. A client who has a potassium level of 3.6 mEq/L.

B. A client who has a sodium level of 128 mEq/L A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.

A nurse assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in affect within 30-60 minutes after taking the medication. B. Greater risk of attempting suicide as affect and energy improve. C. Onset of frequent loose stools. D. Development of physiologic dependence on the medication.

B. Greater risk of attempting suicide as affect and energy improve. An initial response to amitriptyline can develop in one week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is more possible after 1 week of treatment.

A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who was hit for injuries.

C. Call for a team of staff members to help with the situation. 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 himself or others.

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 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? A. Weight gain B. Tinnitus C. Tachycardia D. Increased salivation

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