Coping ATI Practice Assessment Questions

What is Wernicke-Korsakoff syndrome?

Wernicke-Korsakoff syndrome is a type of secondary dementia as a result of thiamine deficiency that is commonly associated with alcohol use disorder. The syndrome results in confusion and memory loss and is treated with thiamine replacement therapy.

A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors? a. "Has alcohol use affected your performance at work?" b. "Have you received prior treatment for substance use disorder?" c. "Do you receive treatment for any mental health disorders?" d. "At what age did you begin drinking alcohol?"

"Has alcohol use affected your performance at work?" -Inquiring about work performance is appropriate to include in a psychosocial assessment related to substance use disorder.

A nurse is teaching a group of clients about St. John's wort. Which of the following information should the nurse include in the teaching? "St. John's wort can be used to treat mild depression." "St. John's wort increases estrogen levels in the body." "St. John's wort can reduce the effectiveness of oral contraceptives." "St. John's wort can lower prostate-specific antigen levels."

"St. John's wort can be used to treat mild depression." The nurse should teach that St. John's wort increases the serotonin level of serotonin-enhancing antidepressants, which may place the client at risk for serotonin syndrome.

A client states, "I just don't know what to do about my partner's drinking. Every time I see him drinking beer, I start to feel extremely anxious." Which of the following is the most therapeutic response by the nurse? "Tell me more about what is going on with your son. Is he still causing problems for you?" "At one time you told me you were drinking regularly with your partner. Are you continuing to do that?" "The next time your partner starts drinking, what is something you might do to decrease your anxiety?" "I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another person's drinking."

"The next time your partner starts drinking, what is something you might do to decrease your anxiety?" This demonstrates the nurse encouraging the client to formulate a plan of action. It allows the client to identify an alternate course of action to a situation she finds troubling. The client is encouraged to continue to explore her feelings and to think about possible options regarding the situation. It also restates and clarifies what the nurse hears the client saying, which gives the client an opportunity to clarify what she has said if needed.

A nurse is planning care for a client who has generalized anxiety disorder. Which of the following intervention should the nurse implement to promote relaxation?A) Assist the client in practicing meditation.B) Recognize the client's spiritual preferences.C) Encourage the client to identify his positive qualities.D) Help the client to identify his previous accomplishments.

A) Assist the client in practicing meditation.

A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess? a. Amylase b. Creatinine c. Aspartate aminotransferase (AST) d. Antidiuretic hormone (ADH)

ANSWER: C. Aspartate aminotransferase (AST)....The greatest risk to this client is liver injury from the combined adverse effects of alcohol and acetaminophen. Therefore, the priority laboratory value for the nurse to evaluate is AST because an elevated level is an indication of liver damage. -The nurse should evaluate the client's amylase level to assess for pancreatitis. However, there is another laboratory value that is the nurse's priority. -The nurse should evaluate the client's creatinine level to monitor renal function. However, there is another laboratory value that is the nurse's priority. -The nurse should evaluate the ADH level of the client to assess for syndrome of inappropriate ADH, CNS infections, hypovolemia, and dehydration. However, there is another laboratory value that is the nurse's priority.

A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.) Anxiety Obsessive-compulsive disorder Schizophrenia Breathing-related sleep disorder Depression

Anxiety, OCD, Depression

A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A) Hyperactive bowel sounds B) Bradycardia C) Hypertension D) Dental erosion

B) Bradycardia

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?A) Discuss alternative coping strategies with the client.B) Identify precipitating factors for ritualistic behaviors.C) Instruct the client on relaxation techniques for use when anxiety increases.D) Provide a structured activity schedule for the client.

B) Identify precipitating factors for ritualistic behaviors.

A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? Hyperactive bowel sounds Bradycardia Hypertension Dental erosion

Bradycardia -Dental erosion is a complication of bulimia due to vomiting.

A nurse is caring for a client who has severe manifestations of acute alcohol withdrawal. To ensure safe care, which of the following nursing actions should the nurse take? (Select all that apply.) a. Administer a sedative. b. Keep the lights on in the client's room. c. Ambulate the client in the hallway. d. Reduce unnecessary stimuli. e. Limit daily fluid intake.

C) Ambulate the client in the hallway. D) Reduce unnecessary stimuli.

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?A) MildB) ModerateC) SevereD) Panic

C) Severe

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?A) Limit the amount of time available to interact with others.B) Focus attention on meaningful tasks.C) Manipulate and control others' behaviors.D) Decrease anxiety to a tolerable level.

D) Decrease anxiety to a tolerable level.

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?A) Attention-seeking conductB) Mild difficulty problem solvingC) Mild fidgetingD) Threatening behavior

D) Threatening behavior

A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client? Diazepam Acamprosate Naltrexone Disulfiram

Diazepam, a benzodiazepine, is used to treat acute alcohol withdrawal. Diazepam helps to decrease the intensity of withdrawal, prevent seizures, and helps to stabilize vital signs.

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.) ​Difficulty relaxing ​Irrational fear of certain objects ​Rule-conscious behavior ​Unaware of compulsions ​Perfectionist behavior

Difficulty relaxing Rule-conscious behavior Perfectionist behavior -Note: People with OCD are aware of their compulsions which causes increased anxiety and shame.

A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan? Contact the crisis counselor once a week. Identify anxiety-producing situations. Try to repress feelings of anxiety. Eliminate stress and anxiety from daily life.

Identify anxiety-producing situations. Treatment for anxiety disorders includes helping the client recognize signs that her anxiety level is rising and the triggers that cause this type of reaction. The nurse should include this information so the client can limit anxiety-provoking situations or intervene early to reduce anxiety levels.

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? Sleeping 12 hr or more each day. Increasing sense of attachment to others. Constant need to talk about the event. Increasing feelings of anger.

Increasing feelings of anger. It is not increased sleeping because insomnia is the sleep-related finding associated with PTSD.

A nurse is caring for a client who has just begun therapy with alprazolam to treat anxiety. The nurse should monitor the client for which of the following adverse effects of this medication? Insomnia Bradycardia Hearing loss Hypertension

Insomnia

A nurse is caring for a client who is withdrawing from opioids. Which of the following medications should the nurse prepare to administer? -Methadone -Disulfiram -Risperidone -Lithium carbonate

Methadone Methadone is a synthetic opiate that blocks the craving for and the effects of narcotics. It is widely used to assist with detoxification and maintenance of those who have a dependency to opioids. Methadone reduces withdrawal symptoms, but it does not cause a high. The medication must be taken every day. The client requires close monitoring because methadone is highly addictive. Methadone is approved for the treatment of women who are pregnant and addicted to opioids.

A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first? Administer diazepam. Raise the side rails of the bed. Obtain a medical history. Start intravenous fluids.

Raise the side rails of the bed. The greatest risk to the client is injury from a fall; therefore, the first action by the nurse is to raise the side rails of the bed.

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take? Encourage the client to go back to bed. Give the client a PRN sleeping medication. Remain with the client. Explore alternatives to pacing the floor with the client.

Remain with the client. Remaining nearby the client will help to alleviate feelings of abandonment and reassures the client of his safety. -Encourage the client to go back to bed. A client who is experiencing severe level of anxiety will not respond positively to going back to bed. -Give the client a PRN sleeping medication. A client who is given a PRN sleeping medication will not be alleviated of severe anxiety. This action will only temporarily suppress the feelings. -Explore alternatives to pacing the floor with the client. A client who is experiencing severe anxiety will not respond to exploring alternatives to pacing.

A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) Seizures Illusions Tremors Polyphagia Nystagmus

Seizures Illusions Tremors

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations? Attention-seeking conduct Mild difficulty problem solving Mild fidgeting Threatening behavior

Threatening behavior. The client experiencing severe anxiety can have feelings of confusion and impending doom. The client may feel the need to be aggressive and defensive, speaking with loud, rapid speech and possibly making threats and demands of others. -Attention-seeking conduct. The nurse should expect a client experiencing severe anxiety to exhibit purposeless behavior. -The nurse should expect a client experiencing severe anxiety to report that problem solving seems impossible. When experiencing severe anxiety, the client's perceptual field is scattered and the client is not able to focus on anything except relieving the anxiety.

A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? a. "The ritualistic behavior provides sexual satisfaction." b. "The client performs ritualistic behavior to boost self-esteem." c. "The ritualistic behavior temporarily relieves anxiety." d. "The client performs ritualistic behavior to decrease feelings of shame."

c. "The ritualistic behavior temporarily relieves anxiety." Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to obsessions.

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take? a. Compliment the client for weight gain. b. Allow the client to eat at any time. c. Provide privacy when friends visit. d. Schedule regular weigh-in times.

d. Schedule regular weigh-in times. Treatment for anorexia nervosa is structured. The client is weighed at regularly scheduled times. The goal is to achieve 90% of ideal body weight. The therapeutic environment for clients who have eating disorders usually consists of designated meal times and adherence to the selected menu. Clients will contract with the staff for rewards based upon regular attendance at meals and the amount of the meal consumed. In addition, the client should be closely monitored after meals to make sure the client is not vomiting. Reinforcement should focus on positive efforts to eat planned meals and participate in other activities of the care plan. Patient privileges are often linked to weight gain and adherence to the plan of care.

A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? "I'm sure that the bugs you see will not harm you." "Tell me more about the bugs that you see in your room." "I don't see any bugs, but you seem very frightened." "I do not see anything. This is part of the withdrawal process."

"I don't see any bugs, but you seem very frightened." -This client is experiencing a tactile hallucination, which is common during alcohol withdrawal. This response by the nurse presents reality and shows empathy by acknowledging the client's feelings.

A client is admitted with post-traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism? The client begins reading a book when he experiences hand tremors in response to loud noise. The client makes a decision to postpone a needed surgery. The client focuses on discussing his daily routine when asked about the fire. The client develops stomach pains when fire is seen on television.

-The client begins reading a book when he experiences hand tremors in response to loud noise. This is an adaptive use of dissociation by temporarily blocking memories and perceptions from conscious thought. Dissociation involves a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. This client has a physical response of hand trembling when he hears loud noise, and chooses to dissociate from the loud noise by reading. -The client makes a decision to postpone a needed surgery. This is a maladaptive use of suppression, which is voluntarily denying unpleasant thoughts and feelings. Suppression is the conscious denial of a disturbing situation or feeling. This client is consciously suppressing the need to get a surgery. -The client focuses on discussing his daily routine when asked about the fire. This is a maladaptive use of intellectualization. Intellectualization is a process in which events are analyzed based on remote cold facts and without passion, rather than incorporating feeling and emotion into the processing. This client chooses to focus on a remote daily routine rather than processing the recent tragedy. -The client develops stomach pains when fire is seen on television. This is a maladaptive use of conversion. Conversion is the unconscious transformation of anxiety into a physical symptom with no organic cause. This client feels anxious when seeing fire on television due to his recent tragedy. This feeling then converts into stomach pains.

A nurse is caring for a client who has Wernicke-Korsakoff psychosis as a result of chronic alcohol use disorder. Which of the following interventions should the nurse anticipate? Laboratory analysis of cardiac enzymes Monitoring for the presence of esophageal varices Administration of thiamine Placing the client in protective isolation

Administration of thiamine Thiamine is administered to the client who has Wernicke-Korsakoff psychosis due to hepatic dysfunction and inadequate intake of sufficient vitamins.

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? Hand tremors. Course tremors of the hands is an expected finding of alcohol withdrawal. Stuporous level of consciousnessStupor is an expected finding of alcohol intoxication rather than withdrawal. BradycardiaTachycardia, rather than bradycardia, is an expected finding of alcohol withdrawal. HypotensionHypertension, rather than hypotension, is an expected finding of alcohol withdrawal.

Hand tremors. Course tremors of the hands is an expected finding of alcohol withdrawal. -Stupor is an expected finding of alcohol intoxication rather than withdrawal. Tachycardia, rather than bradycardia, is an expected finding of alcohol withdrawal. Hypertension, rather than hypotension, is an expected finding of alcohol withdrawal.

A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? Rapid speech Chills Distorted perceptual field Urinary frequency

Urinary frequency. The nurse should expect the client who has moderate anxiety disorder to exhibit urinary frequency, as well as headache, backache, and insomnia. -rapid speech and distorted perceptual field are severe anxiety. Chills and trembling are panic anxiety.

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply). Severe hypotension Visual hallucinations Hyperglycemia Insomnia Tremors

Visual Hallucinations, insomnia, tremors. Other symptoms of alcohol withdrawal are sweating, hypertension, hypoglycemia, restlessness, irritability.

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority? a. Helping the client identify positive personality traits b. Providing for adequate hydration and rest c. Confronting the use of denial and other defense mechanisms d. Educating the client about the consequences of alcohol misuse

b. Providing for adequate hydration and rest Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatment. Rest is important for two reasons: alcohol use disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with increased restlessness and agitation. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.