C1: Exam 3 - ATI

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

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

A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply.) A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be prescribed and dispensed by an approved treatment center."

A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." E. "Methadone must be prescribed and dispensed by an approved treatment center."

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I will need to monitor the client for hyponatremia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."

A. "This medication increases the release of serotonin and norepinephrine."

A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

A. "This medication will help prevent seizures during alcohol withdrawal."

A nurse is discussing routine follow‑up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Serum sodium and potassium

A. AST/ALT and LDH

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

A. Administer the next dose of lithium carbonate as scheduled.

A nurse working in an acute mental health facility is caring for a 35‑year‑old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply.) A. Age B. Gender C. History of chronic asthma D. Smoking E. Being married

A. Age B. Gender C. History of chronic asthma D. Smoking

A nurse is obtaining a health history from the parents of a 12‑year‑old client who has conduct disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Bullying of others B. Threats of suicide C. Law‑breaking activities D. Narcissistic behavior E. Flat affect

A. Bullying of others B. Threats of suicide C. Law‑breaking activities

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply.) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

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

A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Eat a diet high in fiber. B. Check temperature daily. C. Take medication first thing in the morning before eating. D. Add extra calories to the diet as between‑meal snacks

A. Eat a diet high in fiber.

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? A. Install childproof door locks. B. Place rugs over electrical cords. C. Mark cleaning supplies with colored tape. D. Place the client's mattress on the floor. E. Install light fixtures above stairs.

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

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? A. Placing the client on one‑to‑one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects

A. Placing the client on one‑to‑one observation

A nurse is teaching the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Seizures B. Agitation C. Photophobia D. Dry mouth E. Irregular pulse

A. Seizures B. Agitation E. Irregular pulse

A nurse is planning care for a client following surgical implantation of a VnS device. the nurse should plan to monitor for which of the following adverse effects? (Select all that apply.) A. Voice changes B. Seizure activity C. Disorientation D. Dysphagia E. Neck pain

A. Voice changes D. Dysphagia E. Neck pain

A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Void just before taking the medication. B. Increase the dietary intake of potassium. C. Wear sunglasses when outside. D. Change positions slowly when getting up. E. Chew sugarless gum.

A. Void just before taking the medication. C. Wear sunglasses when outside. E. Chew sugarless gum.

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicate an understanding of the teaching? (Select all that apply.) A. "We need to understand that she is responsible for her disorder." B. "Eliminating any codependent behavior will promote her recovery." C."She should participate in an al‑anon group to help her recover." D. "The primary goal of her treatment is abstinence from substance use." E. "She needs to discuss her feelings about substance use to help her recover."

B. "Eliminating any codependent behavior will promote her recovery." D. "The primary goal of her treatment is abstinence from substance use." E. "She needs to discuss her feelings about substance use to help her recover."

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."

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

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash." B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

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

A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."

B. "Regular aspirin would be a better choice than ibuprofen."

A nurse is evaluating a client's understanding of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching? A. "Taking this medication will help reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medicine." D. "Each dose of this medication should be placed under my tongue to dissolve."

B. "While taking this medication, i should keep a pack of sugarless gum."

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A."You should avoid taking over‑the‑counter acetaminophen while on donepezil." B. "You can expect the progression of cognitive decline to slow with donepezil." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

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

A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply.) A. An adverse effect of this medication is CNS depression. B. Administer the medication in the morning. C. Monitor for weight loss while taking this medication. D. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop. E. This medication blocks the blocking the synaptic reuptake of serotonin in the brain.

B. Administer the medication in the morning. C. Monitor for weight loss while taking this medication. E. This medication blocks the blocking the synaptic reuptake of serotonin in the brain.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

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

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessnes

B. Family report of personality changes C. Hallucinations E. Restlessnes

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

B. Fine tremors of both hands D. Vomiting E. Restlessness

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations. B. Offer concise explanations. C. Establish consistent limits. D. Disregard client complaints. E. Use a firm approach with communication.

B. Offer concise explanations. C. Establish consistent limits. E. Use a firm approach with communication.

A nurse is caring for a client who is taking phenelzine for which of the following adverse effects should the nurse monitor? (Select all that apply.) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Headache E. Bruxism

B. Orthostatic hypotension D. Headache

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply.) A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus

B. Polyuria D. Muscle weakness

A nurse is assessing a 4‑year‑old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess? A. Impulsive behavior B. Repetitive counting C. Destructiveness D. Somatic problems

B. Repetitive counting

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

B. Splitting

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Fear of being alone B. Substance use C. Weight gain D. Irritability E. Aggressiveness

B. Substance use D. Irritability E. Aggressiveness

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (Select all that apply.) A. Somnolence B. Yellowing skin C. Increased appetite D. Fever E. Malaise

B. Yellowing skin D. Fever E. Malaise

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

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

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I will use light therapy 30 minutes a day to prevent further recurrences of PMDD." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

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

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit‑setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

C. "I should practice limit‑setting to help prevent client manipulation."

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D."Medication and psychotherapy are most effective during the acute phase of MDD."

C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."

A nurse is assisting with a court‑ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Demonstrates extreme anxiety when placed in a social situation B. Has difficulty making even simple decisions C. Attempts to convince other clients to give him their belongings D. Becomes agitated if his personal area is not neat and orderly E. Blames others for his past and current problems

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

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching? A. Chew the gum for no more than 10 min. B. Rinse out the mouth immediately before chewing the gum. C. Avoid eating 15 min prior to chewing the gum. D. Use of the gum is limited to 90 days.

C. Avoid eating 15 min prior to chewing the gum.

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

C. Bipolar disorder with rapid cycling

A nurse is assisting the parents of a school‑age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply.) A. Allow the child to choose consequences for negative behavior. B. Use role‑playing to act out unacceptable behavior. C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

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

C. Disulfiram

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should anticipate prescriptions for which of the following medications to promote long‑term abstinence from alcohol? (Select all that apply.) A. Lorazepam B. Diazepam C. Disulfiram D. Naltrexone E. Acamprosate

C. Disulfiram D. Naltrexone E. Acamprosate

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place, and person. B. Offer fluids and nourishing diet as tolerated. C. Implement seizure precautions. D. Encourage participation in group therapy sessions.

C. Implement seizure precautions.

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply.) A. Hypotension B. Paralytic ileus C. Memory loss D. Nausea E. Confusion

C. Memory loss D. Nausea E. Confusion

A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect. B. Older adults commonly use rationalization to cope with a substance use disorder. C. Older adults are at an increased risk for substance use following retirement. D. Older adults develop substance use to mask manifestations of dementia

C. Older adults are at an increased risk for substance use following retirement.

A nurse is interviewing a 25‑year‑old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of a minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self‑esteem

C. Presence of manifestations for at least 2 years

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file. B. Instruct the client's partner to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

C. Provide information on resources for respite care.

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression. B. The client currently smokes 1.5 packs of cigarettes per day. C. The client had a motor vehicle crash last year and sustained a head injury. D. The client has a BMI of 25 and has gained 10 lb over the last year.

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

A nurse in a pediatric clinic is caring for a preschool‑age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching? A. "Behaviors associated with ADHD are present prior to age 3." B. "This disorder is characterized by argumentativeness." C. "Below‑average intellectualfunctioning is associated with ADHD." D. "Because of this disorder, your child is at an increased risk for injury."

D. "Because of this disorder, your child is at an increased risk for injury."

A nurse in a long‑term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

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

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I should receive ECT once a week for 6 weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

D. "I will receive a muscle relaxant to protect me from injury during ECT."

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "TMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following TMS." C."TMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for daily TMS treatments for the first several weeks."

D. "I will schedule the client for daily TMS treatments for the first several weeks."

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the priority to report to the provider? A. "My mother has diabetes that is controlled by her diet." B. "My mother recently completed a course of prednisone for acute bronchitis." C. "My mother received her flu vaccine last month." D. "My mother is currently on furosemide for her congestive heart failure."

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

A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step‑by‑step instructions during hygiene activities. D. Monitor the client for escalating behavior.

D. Monitor the client for escalating behavior

A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A. Apply the patch once daily at bedtime. B. Place the patch carefully in a trash can after removal. C. Apply the transdermal patch to the anterior waist area. D. Remove the patch each day after 9 hr.

D. Remove the patch each day after 9 hr.