customer : Practice 5 ( mental health )

FLAG A nurse is caring for a client who states, "My mother and my mother's mother have all been in abusive relationships. We know this is because of what happened to our people 100 years ago with slavery." Which of the following responses by the nurse expresses understanding of the client's trauma?

"It appears that you are explaining historical trauma. Can you tell me more?" CORRECT My Answer This client has identified how historical trauma can affect current experiences of trauma. Asking the client to explain more allows them to discuss their personal experiences and acknowledges what has happened to their family and people group.

FLAG A nurse is caring for a client who is exhibiting a depressed mood one week before the start of their menstrual cycle. The nurse should identify that the client is exhibiting manifestations consistent with which of the following disorders?

Premenstrual dysphoric disorder CORRECT My Answer The nurse recognizes that the depression experienced in premenstrual dysphoric disorder occurs in the week before a client menstruates.

FLAG A nurse is caring for a client following an attempted suicide. The client states, "I can't live with killing my son. I was drunk and he was in the car. It is all my fault" Which of the following considerations focuses on universal trauma precautions in the care of this client?

Use therapeutic communication in all encounters is correct. Universal trauma precautions are the basis for providing trauma-informed care and include using therapeutic communication in all client encounters. Establish an environment where the client feels safe is correct. Universal trauma precautions are the basis for providing trauma-informed care. This includes creating a safe environment where the client can heal. Acknowledge that the client has experienced trauma is correct. Universal trauma precautions are the basis for providing trauma-informed care. This includes the healthcare team members acknowledging the client's trauma. Avoid blaming or shaming the client for mental health behaviors is correct. Universal trauma precautions are the basis for providing trauma-informed care. This includes addressing the client with respect and without judgement, blame, or shame.

FLAG A nurse is caring for a client who has post-traumatic stress disorder and is considering prolonged exposure therapy. The client asks, "How does this therapy work?" Which of the following responses by the nurse accurately describes this type of therapy?

"A therapist helps you safely and gradually face memories or situations related to your trauma that evoke fear." CORRECT This is an accurate description of prolonged exposure therapy, which is a form of cognitive behavioral therapy that includes exposure to situations, people, or objects that the patient is avoiding.

FLAG A nurse is covering a phone triage line for trauma and crisis support. A client on the phone asks, "Can you help me understand how trauma-related disorders develop?" Which of the following responses by should the nurse provide?

"Experiencing or witnessing a traumatic event can result in developing a trauma-related disorder." CORRECT This should be included in the nurse's response. Experiencing or witnessing trauma at any time during one's life can result in developing a trauma-related disorder. It is also important to understand that not all people who experience trauma will develop a trauma-related disorder.

FLAG A nurse is screening children and adolescents for exposure to adverse childhood experiences (ACEs). Which of the following clients is considered to have experienced an ACE?

A 7-year-old who has a parent who is in prison CORRECT My Answer Having a parent or another household member in prison is considered an adverse childhood experience.

FLAG A nurse is caring for a client who has depression. Which of the following noninvasive treatments should the nurse recommend to the client?

Cognitive behavioral therapy CORRECT My Answer The nurse should recommend cognitive behavioral therapy (CBT) as a non-invasive treatment for depression. CBT usually involves meeting with a trained therapist who empowers the client to change behavior by changing their thinking.

A school nurse is planning a presentation about identifying potential warning signs of suicide for high school students. Which of the following examples of behaviors should the nurse include in the teaching?

Displaying extreme mood swings CORRECT The nurse should include in the presentation that sudden and extreme mood swings might be a warning sign that a student is considering suicide.

FLAG A nurse is speaking with the caregiver of a client who has dementia and is experiencing anosmia. Which of the following information should the nurse provide about strategies for managing the client's anosmia?

Dispose of food at the expiration date. CORRECT My Answer The nurse should inform the caregiver to dispose of food at the expiration date due to the client's inability to smell.

A nurse is caring for a school-age child who witnessed a violent crime. Each time the child recalls the event, the details differ from prior recollections. Which of the following trauma-related symptoms is the child experiencing?

Dissociative amnesia CORRECT This child is experiencing dissociative amnesia, which is a negative cognitive symptom resulting in an inability to recall important aspects of the traumatic event.

FLAG A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder?

Benzodiazepines CORRECT My Answer The nurse should identify that benzodiazepines can have an adverse effect of delirium. Benzodiazepines are central nervous system depressants used to treat insomnia, anxiety, and seizures.

FLAG A nurse is creating a presentation about suicide prevention. When providing information about the prevalence of suicide, the nurse should include that a death occurs how often in the United States?

Every 11 min CORRECT The nurse should identify that suicide is the tenth leading cause of death in the United States, accounting for one death every 11 min.

FLAG A nurse is caring for a client who has dementia. The provider has prescribed a protease inhibitor medication for the client. The nurse should identify that this medication is given to treat which of the following types of dementia?

HIV infection CORRECT The nurse should identify that clients who have HIV infection dementia can be prescribed protease inhibitors, antivirals, and non-nucleoside revise transcriptase inhibitors for treatment.

FLAG A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client?

Have toys or drawing materials available for the child. CORRECT Children may require play or creative outlets such as toys or coloring to express thoughts and feelings. This is an appropriate strategy for assessing a child.

FLAG A nurse is reviewing a client's medication administration record and notes a new prescription for tetrabenazine. The nurse should identify that this medication is prescribed to treat which of the following types of dementia?

Huntington's disease CORRECT My Answer The nurse should identify the only medication that is effective in treating Huntington's disease dementia is tetrabenazine.

FLAG A nurse is caring for a client who has dementia. Which of the following requests should the nurse make to determine the client's social cognition?

Identify emotion of faces on cards CORRECT The nurse should determine the client's social cognition by requesting the client to identify emotion of faces on cards. The nurse can also use story questions to elicit information about the mental state of individuals within the story.

FLAG A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide?

Loss of a job CORRECT The nurse should identify that a risk factor for suicide is the loss of a job and therefore should be included in the presentation.

FLAG A nurse is providing care to a 9-year-old child who uses their hand to mimic shooting a gun anytime someone enters the room or tries to interact with them. The nurse should identify that this is an example of which of the following manifestations of post-traumatic stress disorder?

Posttraumatic play CORRECT My Answer This child is exhibiting posttraumatic play, or reenactment of a traumatic event, in which the child repeatedly mimics some aspect of the trauma.

FLAG A nurse is caring for a client who is experiencing lack of sleep, lack of appetite, and difficulties with concentration. Which of the following types of dementia should the nurse expect this client to have?

Prion disease CORRECT The nurse should identify a client who is experiencing lack of sleep, lack of appetite, and difficulties with concentration might have prion disease dementia. Other manifestations can include fatigue, lack of coordination, anxiety, and abnormal movements.

FLAG A school nurse is creating a support group for students following the suicide of one of their peers. Which of the following interventions is the nurse providing?

Promoting connectedness CORRECT By providing a support group to assist the students with the death of their peer, the nurse is promoting connectedness.

FLAG A nurse is caring for a client who has posttraumatic stress disorder (PTSD) and is beginning psychopharmacology therapy. Which of the following medications is considered first-line treatment for symptoms of PTSD?

Sertraline CORRECT Sertraline is a selective serotonin reuptake inhibitor (SSRI). SSRIs are considered a first-line treatment for PTSD symptoms of depression and anxiety.

FLAG A nurse is caring for an adolescent who has experienced abuse and neglect since early childhood. The nurse should understand that this is an example of which of the following types of trauma?

Chronic trauma CORRECT My Answer Chronic trauma refers to multiple and/or persistent traumatic events that a client experiences over time, including long-term abuse and neglect. This type of trauma could also include ongoing isolation, poverty, or hunger.

FLAG A nurse is reviewing a client's MRI results that show cortical thinning. The nurse should identify that this finding is evident in which of the following types of dementia?

Substance use disorder CORRECT My Answer The nurse should identify that cortical thinning is associated with a client who has substance use disorder dementia.

FLAG A nurse is developing a plan of care for a client who was recently diagnosed with a trauma-related disorder. Which of the following client goals should the nurse include?

The client will develop effective coping strategies by discharge is correct. The nurse should help the client identify effective coping strategies to help empower them and restore normal routines. The client will identify triggers for traumatic reexperiencing by discharge is correct. They will also identify strategies for self-regulation they can use if they are triggered. The client will participate in developing their plan of care is correct. The client should participate in the development of their treatment plan because this will help empower them. The client will develop effective coping strategies by discharge is correct. The nurse should help the client identify effective coping strategies to help empower them and restore normal routines. The client will identify triggers for traumatic reexperiencing by discharge is correct. They will also identify strategies for self-regulation they can use if they are triggered. The client will participate in developing their plan of care is correct. The client should participate in the development of their treatment plan because this will help empower them.

FLAG A nurse in a provider's office is caring for a client. Admission Assessment Vital Signs Provider Prescriptions Admission Assessment Day 1 1400: Client seen for annual physical. Client, age 56, no current health issues, lives at home and works full time. Family history of Alzheimer's disease The nurse is providing dietary teaching about the MIND diet to the client to promote cognitive function. Which of the following information should the nurse include in the teaching? (Select all that apply.)

When taking action and providing dietary teaching on the MIND diet, the nurse should include the use of olive oil for cooking, increasing intake of berries, limiting or abstaining from alcohol, eating fish once per week, replacing beans and lentils for meat for most meals, and eating nuts to promote cognitive function.

FLAG A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?

"The stress from my new job could be the cause of my depressed mood." CORRECT The nurse should identify that the causes of mood disorders are an interplay of genetics, neurotransmitter dysfunction, brain dysfunction, neuroendocrine issues, environmental factors such as stress, and psychological factors such as sensitivity to stressors.

FLAG A nurse is responding to a parent of an adolescent who was recently diagnosed with posttraumatic stress disorder following a sexual assault. The parent states, "My child ignores curfew, is hanging out with a rough crowd, and has been experimenting with drugs. Why would they be doing this?" Which of the following responses should the nurse make?

"This must be a difficult time for you. Adolescents who have experienced a trauma may exhibit increased reckless behaviors." CORRECT My Answer This is the most appropriate response because it is therapeutic and responds to the parent's question. Adolescents who have experienced trauma may respond in reckless behaviors.

FLAG A nurse is preparing a client for electroconvulsive therapy (ECT). Which of the following client statements indicates an understanding of the procedure?

"This procedure will cause me to have brief seizures." CORRECT While an electrocardiograph (ECG) and electroencephalograph (EEG) monitor the client, brief seizures are induced by electrical current attached to one or both sides of the forehead.

FLAG A nurse is caring for a client who has recently experienced a mental health crisis which resulted in the client being physically restrained. Which of the following statements by the client indicates the client is indicate that the crisis has passed?

"I am feeling calmer and am hungry. I think I'm ready to talk about what happened." CORRECT My Answer This client statement indicates that they have become calm and are willing to reflect on the situation. This client is demonstrating being at a functional level which is safe and that the mental health crisis has passed. Recognition of being hungry and feeling calmer as well as willing to talk about what happened reflect return to a stable level of functioning.

FLAG A nurse is caring for a client who is recovering from a femur fracture sustained in a motor-vehicle crash. Their partner died in the collision. Which of the following client statements would indicate that the client is experiencing avoidance symptoms?

"I don't want to think or talk about what happened with anyone." CORRECT This is an example of an avoidance symptom. A client experiencing avoidance symptoms will make an effort to avoid memories, conversations, thoughts, and feelings about their traumatic experience. They may also avoid people, places, or objects that remind them of their trauma.

FLAG A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?

"I'm going to give my sister my pottery collection when I get home." CORRECT The nurse should identify that clients who are considering self-harm often give away their favorite personal belongings.

FLAG A nurse is providing an in-service to a group of nurses on medications used to treat the progression of Alzheimer's disease. Which of the following medications should the nurse include in the teaching?

Aducanumab CORRECT My Answer The nurse should identify that aducanumab, an amyloid beta-directed antibody, is used to treat the progression of Alzheimer's disease.

FLAG A community health nurse is preparing an educational activity on Alzheimer's disease. Which of the following risk factors should the nurse include as the greatest risk for this disease?

Age CORRECT The nurse should identify the greatest risk for Alzheimer's disease is age.

FLAG A nurse is caring for a client who has dementia and has been placed on the MIND diet plan. Which of the following foods should the nurse offer the client for a snack?

Almonds CORRECT The nurse should recommend almonds to the client for a snack. Almonds are high in omega-3 fatty acids, which can slow the progression of or delay the disease.

FLAG A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

Ask the client about the lethality of their plan. CORRECT The nurse should identify that clients who are having suicidal ideation should be assessed for plans they have made as well as the lethality of their plans. Asking the client about the lethality of their plans will allow the nurse to learn more about the client's plans. The nurse should notify the client's treatment team of the client's suicide lethality plans.

FLAG A nurse has volunteered to provide care following a human-caused disaster. Which of the following settings are related to a human-caused disaster?

Providing medical aid following a bomb explosion is correct. This is an example of a human-caused disasters as one or more humans were responsible for the situation. Providing support to a school nurse following a school shooting is correct. School shootings are considered human-caused disasters as one or more humans were responsible for the situation. Providing care to the emergency department due to a local chemical spill is correct. A chemical spill is considered a human-caused disaster. Nurses may be deployed to respond to the disaster which can occur internally in a hospital or within a community response team.

FLAG A nurse is planning for a therapy dog to visit a client who has dementia. Which of the following is the purpose for this activity?

Relax the client CORRECT The nurse should identify that pet therapy can assist clients who have dementia to relax and cope.

FLAG A nurse is caring for a school-aged client. Nurses' Notes History and Physical Nurses' Notes 0900: School aged client brought to the clinic by parents directly from school for physical aggression toward peers. 1000: The child begins screaming and hitting their parents. The parent begins to cry and states, "I just do not know what to do anymore. I cannot take this." Complete the following sentence by using the lists of options.

The nurse should analyze cues to compare client findings to evidence-based resources and standards of care. The client is at risk for developing disruptive mood dysregulation disorder due to severe, recurrent outbursts out of proportion to the situation. Other diagnostic criteria for disruptive mood dysregulation disorder include onset of symptoms before the age of 10, but diagnosis is made between the ages of 6 and 18 years of age. Symptoms must be present for 12 months or more, and symptoms should be present in at least two settings.

FLAG A nurse is providing care to a client who has acute stress disorder. Which of the following client statements is consistent with this disorder?

"I was in a car crash 2 weeks ago and I have nightmares when I sleep." CORRECT My Answer This client's symptoms are consistent with acute stress disorder, which lasts between 3 days and 1 month after the traumatic event. If symptoms last beyond 1 month, then a mental health provider may consider a diagnosis of posttraumatic stress disorder.

FLAG A school nurse is reviewing teacher concerns regarding the recent behavior of a school-age child. Which of the following findings is an indication of toxic stress?

Acting out in the classroom is correct. Frequent behavioral problems can be a sign that a child is experiencing toxic stress due to the effect of trauma. Smoking in the bathroom is correct. Early initiation of smoking can be a sign that a child is experiencing toxic stress due to the effect of trauma. Falling asleep during class is correct. Sleep disturbance, which includes falling asleep during class, can be a sign that a child is experiencing toxic stress due to the effect of trauma. Reporting frequent headaches or stomach pain is correct.Frequent headaches or illness can be a sign that a child is experiencing toxic stress due to the effect of trauma.

FLAG A nurse is preparing to give a hand-off report regarding a client who has acute stress disorder following a suicide attempt. Which of the following symptom domains of trauma should the nurse include in the report?

Cognitive, Emotional, Behavioral and Physical CORRECT Nurses should assess a client's symptoms cues affecting the cognitive, behavioral, physiological, and emotional domains.

FLAG A nurse is planning care for a client who has dementia. The provider has prescribed massage therapy for the client. Which of the following should the nurse identify as the purpose for this treatment?

Decrease depression CORRECT The nurse should identify that massage therapy along with medication can be effective in decreasing depression for a client who has dementia.

FLAG A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?

Delusions CORRECT My Answer The nurse should identify that clients who have depression may exhibit manifestations of delusions or hallucinations. These findings are characteristic of psychotic depression.

FLAG A nurse is caring for a client who is exhibiting symptoms of emotional and physical trauma. Which of the following nursing actions is a priority when providing trauma-informed care for this client?

Ensure that the client is safe. CORRECT My Answer Ensuring client safety is the priority nursing action. Confirming that the client is physically and psychologically safe is the beginning point of healing.

FLAG A nurse is caring for a client who has a headache and abdominal pain. When asked when the symptoms began, the client stops talking and turns away. The nurse understands that this response may reflect a prior experience of trauma. Which of the following defense mechanisms most accurately explains the client's response?

Freeze response CORRECT The client is experiencing a freeze response. This can happen when the client becomes overwhelmed by the memory of the traumatic event, which causes the thinking centers of the brain to shut down, and the client may be unable to process new information. A freeze response is evident in how the client avoids the nurse's question about their symptoms.

FLAG A nurse is caring for a client who has dementia and observes that the client becomes stressed and requires assistance and monitoring when their family visits. When the family leaves the room, the client returns to baseline and the deficits are gone. Using the Functional Assessment Stage Tool, the nurse should identify that the client is in which of the following stages of Alzheimer's disease?

Incipient CORRECT The nurse should identify that the client is in the incipient stage of Alzheimer's disease. In the incipient stage, the client requires assistance and monitoring when stressful events arise. After the stressful event, the client returns to baseline and the deficits are gone.

FLAG A nurse is responding to a client diagnosed with acute trauma disorder following the sudden death of their child. The client is pacing, wringing their hands, and crying stating "I am just so angry!" The client's vital signs are heart rate 108/min, blood pressure 142/82 mm Hg, and respiratory rate 24/min with shallow respirations. Which of the following nursing actions should the nurse take?

Keep hands where the client can see them is correct. This action can nonverbally communicate support and empathy, as well as diminish any threatening nonverbal body language. Acknowledging what the client is experiencing and willingness to help is correct. This is an appropriate response as this provides therapeutic presences and suggests partnering toward a solution. Ensure the client has adequate personal space is correct. Staying at least an arm's length away from the client shows respect for their personal space and ensures safety for both the client and the staff.

FLAG A public health nurse is applying for a grant related to suicide prevention. When describing social groups at highest risk, which of the following should the nurse include?

Native American CORRECT The highest rates of suicide are among Native American and non-Hispanic White Americans, veterans, people in rural areas, and people who work in certain industries like mining and construction.

FLAG A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse what type of essential oils should be used when the client receives massage therapy to decrease anxiety. Which of the following oils should the nurse recommend?

Rosemary CORRECT The nurse should recommend the use of rosemary oil. Essential oils such as rosemary, lemon, and lavender are effective when used during massage to decrease anxiety, improve sleep, and improve cognitive function for clients who have Alzheimer's disease.

FLAG A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include?

SAFE-T is correct. The SAFE-T assessment addresses a client's level of suicide risk and offers interventions. SAD PERSONS is correct. The SAD PERSONS scale is a suicide risk assessment that utilizes an acronym for easy learning. The scale is based on 10 major risk factors. PHQ-9 is incorrect. The PHQ-9 is a quick, nine-question assessment that a client can self-administer to determine depression manifestations. It does not assess suicide risk.

FLAG A nurse assigned to a mental health hotline receives a call from a nurse who has been working on a Covid-19 unit. The caller states, "I just don't think I can be a nurse anymore." Which of the following types of trauma should the nurse recognize this person is experiencing?

Secondary trauma CORRECT Nurses and other health care professionals are at risk for secondary trauma due to the repeated witnessing of client trauma and death. Incidents of secondary trauma have increased during the Covid-19 pandemic.

FLAG A nurse is caring for a client who is experiencing mild depression and asks about herbal treatments. The nurse should identify that which of the following herbal treatments is used for depression?

St. John's Wort CORRECT The nurse should explain to the client that St. John's Wort is an herbal supplement that is used as an alternate therapy for depression. The supplement should not be used in addition to an SSRI medication as this can lead to serotonin syndrome.

FLAG A nurse is caring for a client whose family has been reported missing. The client is visibly agitated; they are pacing and disregards the nurse's directives. The client loudly tells the nurse, "I want answers NOW". The nurse should identify that this client is in which of the following stages of crisis?

Stage 3 CORRECT This client is experiencing severe, escalating symptoms of crisis consistent with stage 3. The client's emotional capacity is diminished. They may be physically agitated and restless, and they may fixate on what is currently taking place.

FLAG A nurse is reviewing assessment findings for a 9-year-old child whose family home was destroyed in a wildfire. The nurse should identify that which of the following behaviors is related to the traumatic

The child is found making small fires in the backyard. CORRECT Children often reenact trauma through play; this is a clinical manifestation of trauma. The parents should seek follow-up care and further education on clinical manifestations of trauma.

FLAG A nurse on an inpatient unit is creating an educational presentation on bipolar disorder. Which of the following should the nurse plan to include in the presentation?

The prevalence of bipolar disorder in adults is estimated at 2.8%. CORRECT The nurse should identify that the prevalence of bipolar disorder in the United States among adults aged 18 or older is estimated to be at 2.8%, affecting 2.9% of men and 2.8% of women.

FLAG A nurse on an inpatient unit is caring for a group of clients who have depression. When planning care, which of the following clients should the nurse see first?

A newly admitted client who has bipolar I disorder CORRECT The nurse should identify that clients who have bipolar disorder can have severe manifestations of both depression and mania. Client safety should remain the priority and the nurse should conduct a thorough history regarding the client's illness.

FLAG A nurse is caring for a client who has Alzheimer's disease and is having difficulty with multitasking. Which of the following cognitive deficits is the client experiencing?

Executive function CORRECT The nurse should identify a client who has Alzheimer's disease and is having difficulty with multitasking is experiencing a cognitive deficit of executive function. Executive function includes planning, decision making, mental flexibility, and a working memory.

FLAG A nurse is monitoring a client who has been diagnosed with post-traumatic stress disorder (PTSD). The nurse recognizes that people diagnosed with PTSD may exhibit symptoms similar to which of the following mental health disorders?

FLAG A nurse is monitoring a client who has been diagnosed with post-traumatic stress disorder (PTSD). The nurse recognizes that people diagnosed with PTSD may exhibit symptoms similar to which of the following mental health disorders?

FLAG A nurse is caring for a client who has experienced a stroke and exhibits parkinsonian effects. The client's cognition fluctuates. Which of the following types of dementia should the nurse expect the client to have ?

Lewy body disease CORRECT The nurse should expect the client to have Lewy body disease dementia. Clients who have Lewy body disease dementia often experience a stroke and exhibit parkinsonian effects along with fluctuating cognition.

FLAG A nurse is caring for a client who is experiencing fluctuating cognition and visual hallucinations. Which of the following types of dementia should the nurse expect this client to have?

Lewy body disease CORRECT The nurse should identify a client who is experiencing fluctuating cognition along with visual hallucinations might have Lewy body disease dementia. Other manifestations can include parkinsonism (bradykinesia, tremors, muscle rigidity), rapid eye movement during sleep, and neuroleptic sensitivity.

FLAG A nurse is caring for a client who has a head injury. The client states they fell off a ladder while painting approximately 2 hr ago and lost consciousness for 45 min according to their partner. The nurse should determine that the client is experiencing which of the following classifications of traumatic brain injury?

Moderate CORRECT According to the severity rating scale for traumatic brain injury (TBI), the nurse should determine the client's injury is moderate because the client lost consciousness for longer than 30 min along with posttraumatic amnesia from 24 hr to 7 days and a Glasgow score of 9 to 12.

FLAG A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home?

Necklace is correct. The nurse should identify that a necklace could be used to commit self-harm by a client who has suicide ideation. The necklace could be used as a choking device and should be sent home with the client's partner. Lace-up tennis shoes is correct. The nurse should identify that the laces of the tennis shoes could be used to commit self-harm by a client who has suicide ideation. The laces of the shoes could be used as a choking device and should be sent home with the client's partner. Glass framed picture of the client's partner is correct. The nurse should identify that a glass framed picture could be used to commit self-harm by a client who has suicide ideation. The glass could be used as a cutting device and should be sent home with the client's partner.

FLAG A nurse is caring for a client who has HIV infection dementia and has progressed to AIDS. Which of the following findings should the nurse expect?

Night sweats CORRECT The nurse should identify that night sweats are a manifestation of AIDS. Other manifestations include fever, headache, weight loss, sore throat, and swollen lymph nodes.

FLAG A nurse is reviewing the medical record of a client who is being admitted with dementia. The nurse notes that the client has worked as a pest control specialist for the last 20 years. Which of the following types of dementia should the nurse expect the client to be experiencing?

Parkinson's disease CORRECT The nurse should expect that a client who has dementia and has worked with pesticides for the past 20 years might have Parkinson's disease dementia. Working with herbicide and pesticides are related to client's who have Parkinson's disease dementia.

FLAG A nurse is caring for a client who has dementia and has a prescription for levodopa. Which of the following types of dementia should the nurse identify that the client has?

Parkinson's disease CORRECT The nurse should identify the client has Parkinson's disease dementia. Levodopa is a medication used to treat this type of dementia.

FLAG A nurse is caring for a client who has posttraumatic stress disorder (PTSD). The nurse anticipates the provider might prescribe which of the following medications?

Paroxetine CORRECT The first treatment for PTSD is a selective serotonin

FLAG A nurse in the clinic is assessing a postpartum client. The client states that they sleep all the time and are hearing voices telling them to harm their child. The nurse should identify that the client is likely experiencing which of the following?

Psychotic depression CORRECT My Answer The nurse should identify that the client is exhibiting manifestations of depression with psychotic features, such as hallucinations.

A nurse is caring for a preschool-aged client who appears malnourished and dehydrated. Admission Assessment Nurses' Notes Admission Assessment Day 1 1400: Skin grayish in color and cold to touch. Decreased skin elasticity noted with prolonged capillary refill time of 3 seconds. Respiratory rate is rapid for client's age. Client is youngest of 3 siblings. Nurses' Notes Day 3 0900: Food tray noted across the room and not in reach of client. Caregiver eating takeout food from a local restaurant. Observed caregiver with client over last several days. No physical contact between child and caregiver. Caregiver interacts with child only when nurse requests assistance. Client reacts minimally to comforting measures implemented by nurse and turns away from nurse and caregiver when distressed. Caregiver states, "I am not a touchy feely sort of person, and my other kids have survived." Complete the following sentence by using t

The nurse should analyze the findings and determine that the client is at highest risk of developing reactive attachment disorder as evidenced by the client's lack of a reaction to comforting measures. Reactive attachment disorder is distinguished by developmentally inappropriate attachment behaviors related to lack of nurturing and comfort during early childhood development.

FLAG A nurse is discussing a trauma-informed approach to care with a peer. Which of the following statements by the nurse reflects an understanding of self-reflection?

To keep clients safe and promote healing, it is important to intentionally consider my words and actions." CORRECT This response indicates an understanding of self-reflection. Self-reflection is an important part of trauma-informed care, because effective communication with the client promotes an environment of safety, equity, and inclusion.

FLAG A nurse is providing dietary teaching to a client who has been diagnosed with Alzheimer's disease about including foods to decrease the progression of the disease. Which of the following foods should the nurse recommend?

Tuna sandwich CORRECT The nurse should recommend tuna sandwiches for the client. Fish is high in omega-3 fatty acids, which can delay or slow the progression of the disease.

A nurse on a behavioral health unit is caring for a client. Nurses' Notes History and Physical Provider Prescriptions Laboratory Results Nurses' Notes 0800: Client observed at breakfast wearing hospital scrubs with the bottom of the pants rolled up and shirt arranged like a halter top. Client sat for less than 5 min and consumed half a piece of toast. Client took the juice box when leaving the table. Observed consuming juice and then dropping the box on the counter. The client reports not sleeping for 2 days. 1300: Client arrived at group. Moved chairs into a cluster and found a seat in the middle. Talkative, interrupting others despite reminders to allow all members to take a turn. After 10 min, client stood, paced quickly around the day room, and eventually left the group. Observed client entering another client's room, yelling out, "Yoo-hoo! Are you here?" Redirected by staff out of room and led to day room. Invit

When using Maslow's hierarchy of needs, the nurse determines that the priority finding is physical exhaustion because of the client's constant motion, risk for inadequate nutritional intake, and altered judgment when in a manic state. Because of the manic state, the nurse should encourage frequent rest periods throughout the day. Excessive physical activity can lead to exhaustion. The nurse should also decrease the environmental stimuli as much as possible. The client is prescribed lithium, and it is important for the client to maintain adequate fluid and sodium intake. The client has a lithium and sodium level that are within normal limits. The client is taking aripiprazole and neuroleptic malignant syndrome is a potential adverse effect of the antipsychotic medication, but the client has not manifestations of the syndrome.

FLAG A nurse is caring for a client, in an outpatient setting, who is experiencing poor appetite, fatigue, and thoughts of hopelessness. The nurse uses the SAD PERSONS scale to further assess. Which of the following items is included in SAD PERSONS?

Previous attempt of suicide CORRECT My Answer The nurse should identify that the SAD PERSONS scale does include the risk factor of a previous attempt of suicide as an item. Each risk factor is one point, and the total scale score is calculated to assist in determining need for referral or admission.

FLAG A nurse is planning care for a client who has Alzheimer's disease and is in the terminal phase. Which of the following findings should the nurse expect?

Unable to sit up CORRECT The nurse should identify that a client who is unable to sit up is in the terminal phase of Alzheimer's disease. Other manifestations can include the client not being unable to hold their head up or smile, requiring total care, and assuming the fetal position when lying down.

FLAG A nurse is admitting a client who has dementia related to a traumatic brain injury. Which of the following findings should indicate to the nurse that the client's condition is worsening?

Visual field cuts CORRECT The nurse should identify that visual field cuts are a manifestation for a client who has experienced a traumatic brain injury. Other manifestations can include anosmia, hemiparesis, decreased cognitive function, and seizures.

FLAG A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Nurses' Notes History and Physical Nurses' Notes Day 2 1000: Client participating in group and individual therapy sessions. Client frequently speaks of the major loss of life associated with the COVID-19 pandemic. States, "I see their faces in my dreams at night." Client admits symptoms have worsened over the last few years, which is why they are currently seeking in-patient treatment. States, "I am so used to taking care of everyone else, I feel guilty having people take care of me." The client asks the nurse, "Why did this happen to me?" The nurse should include which of the following in their response? Select all that apply.

Manifestations of PTSD are higher amongst military personnel" is correct. Risk factors for PTSD include witnessing adverse events that happen to others and repeated exposure to adverse or traumatic events. Military personnel and healthcare workers are at a greater risk of developing PTSD because of the repeated exposure to stressful and adverse events. "Medical personnel working in EDs or ICUs have a high risk of developing PTSD" is correct. Risk factors for PTSD include witnessing adverse events that happen to others and repeated exposure to adverse or traumatic events. Military personnel and healthcare workers are at a greater risk of developing PTSD because of the repeated exposure to stressful and adverse events. Witnessing the frequent loss of life is a high risk factor" is correct. Risk factors for PTSD include witnessing adverse events that happen to others and repeated exposure to adverse or traumatic events. Military personnel and healthcare workers are at a greater risk of developing PTSD because of the repeated exposure to stressful and adverse events.

A nurse is caring for a client. Admission Assessment Medication Administration Record Laboratory Results Vital Signs Admission Assessment Day 1 0900: Client has ulcerative colitis and depression. Client's family states the client has been vomiting and experiencing diarrhea with limited food and fluid intake for the last 3 days. Client recently increased dosage of acetaminophen and increased dosage of prednisone. Urinary output is less than 30 mL/hr for past 2 hr. Client confused to person, place, and time. Medication Administration Record Day 1 0905: Prednisone 40 mg PO daily Lorazepam 0.5 mg PO every 6 hr or as needed for anxiety Amitriptyline 50 mg PO daily Laboratory Results Day 1 0910: Review of Laboratory Results 3 months ago Potassium 4.5 mEq/L (3.5 to 5.0 mEq/L) Sodium 143 mEq/L (135 to 145 mEq/L) Chloride 106 mEq/L (98 to 106 mEq/L) Total calcium 9 mg/dL (9.0 to 10.5 mg/dL) Magnesium 1.6 mEq/L (1.3 to 2.1 mEq

When analyzing cues, the nurse should determine the cause of delirium. The nurse should review the client's medication and look for use of corticosteroids, antidepressants, and benzodiazepines as these medications can cause delirium. Electrolyte imbalances and dehydration should also be monitored and treated. Manifestations of dehydration include increased urine specific gravity, decreased urinary output, increased creatinine levels, and increased BUN, which can cause delirium. These findings can be associated with hypotension, tachycardia, and a decreased oxygen saturation level.

FLAG A nurse at a primary care clinic is assessing a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?

"I can't get my mind to stop racing at night. I'm only sleeping a couple of hours." CORRECT The nurse should identify that insomnia and hypersomnia can both be findings of depression.

FLAG A nurse in a provider's office is caring for a client. Admission Assessment Vital Signs Provider Prescriptions Admission Assessment Day 1 1400: Client seen for annual physical. Client, age 56, no current health issues, lives at home and works full time. Family history of Alzheimer's disease Vital Signs Day 1 1405: Temperature 37.1° C (98.8° F) Blood pressure 110/80 mm Hg Heart rate 172/min Respiratory rate 16/min Provider Prescriptions Day 1 1445: Provide teaching on the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) The nurse is providing dietary teaching about the MIND diet to the client to promote cognitive function. Which of the following information should the nurse include in the teaching? (Select all that apply.)

When taking action and providing dietary teaching on the MIND diet, the nurse should include the use of olive oil for cooking, increasing intake of berries, limiting or abstaining from alcohol, eating fish once per week, replacing beans and lentils for meat for most meals, and eating nuts to promote cognitive function.

FLAG A nurse is preparing a presentation about trauma for a group of newly licensed nurses. Which of the following should be included to describe prevalence of trauma and trauma-related events?

More than 70% of adults worldwide have experienced trauma during their life is correct. The majority of adults worldwide will experience trauma during their lifetime. This can be a single event such as a car accident or repeated exposure to events, such as abuse. Of trauma- and stress-related disorders, post-traumatic stress disorder (PTSD) is the most common diagnosis is correct. PTSD is the most recognized and diagnosed disorder of the trauma-related disorders. The LGBTQIA population experiences a higher occurrence of trauma-related disorders than the general population is correct. Trauma-related disorders have been disproportionately diagnosed among people identifying as LGBTQIA when compared to the general population. This is thought to be related to a higher rate of traumatic exposure to discrimination and acts of violence. Military personnel, first responders, and health care professionals are at higher risk of developing PTSD than the general population is correct. Trauma-related disorders have been diagnosed at a higher rate among military personal, first responders (fire fighters, police), and health care professionals when compared to the general population. This is thought to be related to the exposure to trauma or traumatic events within the scope of their professions.