Mental Health Midterm Practice Questions

Clozapine, an atypical antipsychotic, is prescribed for a client with psychosis. It is important for client to have frequent blood tests for which possible complication?

Agranulocytosis Rationale: A decrease in granulated WBC's is common in those who take clozapine

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program?

Alcoholism involves the entire family. Rationale: Roots of alcoholism are in the family origin

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply.

Anxiety Diaphoresis Psychomotor agitation

Which drug causes euphoria and hallucinations in an addicted adolescent but does not show any ill effects when withdrawn abruptly?

Cannabis Rationale: It's a mind-altering drug that does not cause physical dependence

Which drug is a high-potency medication used to treat schizophrenia?

Fluphenazine

According to current studies, what percentage of adolescents has used alcohol by the end of high school? Record your answer using a whole number. _____%

85%

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism?

Active membership in Alcoholics Anonymous Rationale: Members dint empathy, patience and understanding through this group

While assessing the vital signs of an elderly alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. What other findings does the nurse expect to observe? Select all that apply.

Body temp of 84.2F BP of 100/62 mmHg RR of 12 breaths/min Rationale: Alcohol acts as a vasodilator in the body

A client remains depressed even after an 8-week trial on several antidepressant medications. A decision to initiate electroconvulsive therapy (ECT) is being considered by the treatment team. Which condition is a contraindication to ECT?

Brain tumor Rationale: Treatment increases intracranial pressure

An individual with a history of verbal and physical abuse of others is beginning to demonstrate aggressive behavior toward a visitor. Place the following nursing interventions in the appropriate order to best ensure milieu safety.

Calmly addressing the individual by name to redirect the client's attention Suggesting to the client, "Walk with me to your room." Firmly stating that aggressive behavior like this cannot be tolerated because "someone may get hurt" Explaining that the client will be placed in seclusion if the aggressive behavior continues Reassuring the client that the staff will help control the aggressiveness if the client is unable to do so

Which is a second-generation antidepressant drug?

Citalopram

Which statement is true regarding antipsychotic drugs?

Clozapine is more effective than other second-generation antipsychotics. Rationale: Clozapine is a 2nd generation antipsychotic drug that is more effective than other 2nd generations

The nurse assesses a client with bipolar disorder. While reviewing the laboratory reports, the nurse finds the client's lithium levels are 1.3 mEq/L (1.3 mmol/L). Which nursing intervention would be appropriate in this client?

Continuing to administer the drug Rationale: The normal range of lithium is below 1.5mEq/L

While assessing a client with schizophrenia who is receiving chlorpromazine, the nurse finds lead pipe rigidity, sudden high fever, and sweating. Which drugs would be prescribed by the healthcare provider? Select all that apply.

Dantrolene Bromocriptine Rationale: Lead pipe rigidity, high sudden fevers and sweating are symptoms of NMS

A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display?

Decrease of verbal expression related to slowed thought processes Rationale: As depression increases, thought processes become slower and verbal expression decreases due to a lack of emotional energy

A client who takes insulin for type 1 diabetes has a psychosis and is to receive haloperidol. Which response does a nurse anticipate with this drug combination?

Decreased control of the diabetes Rationale: This medication alters the effectiveness of exogenous insulin

A nurse is counseling a client who abuses cocaine. The nurse recognizes that this drug is representative of which drug category?

Stimulant Rationale: Creates experiences similar to but more intense than amphetamines

A cocaine addict remanded for rehabilitation by the court is angry at being hospitalized. When his wife comes to visit, he is furious and curses at her. He refuses to visit with her and tells her to go home. The wife leaves in tears. What should the nurse say to the client?

"Let's talk about what just happened." Rationale: The client's behavior must be addressed because ignoring it may be interpreted as approval

After detoxification a client with a long history of alcohol abuse decides to attend Alcoholics Anonymous (AA) meetings at the hospital. On the day of the second meeting the client says, "I can't go to the AA meeting today because I'm expecting an important phone call." What is the most therapeutic response by the nurse?

"You are expected to go to the meeting." Rationale: This helps the client recognize and adhere to established limits and goals

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicate that the client is hearing voices. When a nurse begins to walk toward the client, the client pulls out a large knife. What is the best approach by the nurse?

Firm Rationale: A firm approach prevents anxiety transference and provides structure and control for a client who's out of control

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate?

Flight of ideas Rationale: This is a fragmented, pressure, consequential pattern of speech during a manic episode

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?

Keep the client under close observation. Rationale: Likelihood of suicidal ideation being acted out increases with energy return

A client with the diagnosis of schizophrenia, paranoid type, appears very suspicious of the nurse. What is the most effective therapeutic nursing approach?

Making brief, frequent contacts with the client Rationale: These are less threatening and help to build trust

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on?

Potential for self-harm Rationale: Client safety is always the priority

The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement?

Referring the client to a psychiatric healthcare provider as prescribed Rationale: Assessment and management of this illness are beyond the scope of a maternity nurse

What is most important for the nurse to do when caring for a client who is in an alcohol detoxification program?

Accept the client as a worthwhile person. Rationale: Alcohol abusers characteristically have low self-esteem

Which priority assessments should be included by the nurse when caring for a client who is experiencing depression? Select all that apply.

Appetite Activity status Emotional status Rationale: These help determine the level of depression. Irritability and restlessness are secondary assessments

A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is most appropriate for the nurse to implement?

Assuring the client that the symptoms are part of the withdrawal syndrome Rationale: This provides reality-based feedback for the client who is withdrawing

A nurse plans to give greater responsibility for self-control to clients with a long history of alcohol abuse who are about to enter a detoxification program. What should the nurse plan to do?

Help them adopt more healthful coping patterns. Rationale: Coping skills are necessary if drinking is to be stopped

Which atypical antipsychotics are approved for long-term use to prevent the recurrence of mood episodes in clients with bipolar disease? Select all that apply

Olanzapine Ziprasidone Aripipazole Rationale: They're atypical antipsychotics approved for long-term use

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine?

Risk for self injury

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?

Keep the client under close observation. Rationale: As the client's motivation and energy return, the likelihood of suicidal ideation being acted out increases

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior?

Performing passive range-of-motion exercises three times a day for effective joint health Rationale: Excessive and extensive maintenance of posture. This focuses on the joint mechanics

Which drug would be used to treat a client with severe motor tics, barking cries, and outbursts of obscene language?

Pimozide Rationale: These are signs of Tourette syndrome which this drug is used to tread

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization?

Project involving drawing Rationale: May be worked at one's own pace

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine?

Risk for self-injury Rationale: More apt to hurt themselves than others

A client with a history of heavy drinking is brought to a psychiatric facility in a stupor. On the day after admission the client is confused, disoriented, and delusional. What alcohol-related symptom does the nurse decide the client may be experiencing?

Withdrawal syndrome Rationale: CNS is affected by the abrupt withdrawal resulting in delusion, disorientation and confusion

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower?

"I'll help you take your shower now." Rationale: It's direct and does not require the patient to make a decision

A client with schizophrenia reports having ongoing auditory hallucinations and describes them as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse?

"Try to ignore the voices." Rationale: Sometimes auditory hallucinations can be pushed to the side

A client scheduled to begin electroconvulsive therapy (ECT) to treat severe depression that has not responded to any of the antidepressant medications tells the nurse, "I'm scared that I'll lose my memory forever after the treatment." What is the most therapeutic response by the nurse?

"You'll experience a temporary loss of memory, and feeling frightened about it is expected." Rationale: Giving the client simple facts and assuring them that being frightened is expected eases the client's fears

A client scheduled to begin electroconvulsive therapy (ECT) to treat severe depression that has not responded to any of the antidepressant medications tells the nurse, "I'm scared that I'll lose my memory forever after the treatment." What is the most therapeutic response by the nurse?

"You'll experience a temporary loss of memory, and feeling frightened about it is expected." Rationale: Giving the client simple facts and reassuring helps ease their fears

A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client?

Ambivalence Rationale: This is the existence of two conflicting emotions, impulses or desires

A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous (AA) meeting. What is a basic principle of this group?

Amends must be made to each person who has been harmed. Rationale: 8th step is making amends

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? Select all that apply.

Bouts of crying Self-destructive arts Feelings of worthlessness Rationale: Delusions are associated with schizophrenia and depressed folk are social withdrawn

Which drug most commonly causes extrapyramidal side effects (EPS)?

Haloperidol Rationale: It's a typical antipsychotic

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance?

Thiamine deficiency Rationale: This is the primary cause of alcohol-induced amnestic disorder

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing?

Illusion Rationale: Misinterpretation of a real sensory stimulus

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason that this defense is so often used

It reduces feelings of guilt Rationale: This reduces anxiety and protects them

A 55-year-old client who has a long history of drug and alcohol abuse mentions taking ginkgo biloba. The nurse knows that ginkgo biloba is taken to treat what condition?

Memory impairment

Olanzapine is prescribed for a client with bipolar disorder, manic episode. What cautionary advice does the nurse give the client?

Sit up slowly Rationale: It can cause orthostatic hypotension

A client is hospitalized with social anxiety disorder. The client has a history of exhibiting intense, irrational fear of being scrutinized by others. Which primary anxiolytic medications would be prescribed to the client? Select all that apply.

Alprazolam Clonazepam Rationale: Amprazolam and clonazepam are benzodiazepines that are well tolerated in clients and create immediate benefits

A healthcare provider prescribes clozapine to a client with schizophrenia. Which parameters should be assessed before initiating the drug? Select all that apply.

BMI WBC count Absolute neutrophil count Rationale: May lead to weight gain and decrease in WBC count

A client with alcohol dependence is admitted to the detoxification unit. Which class of medication does the nurse anticipate that the healthcare provider will prescribe?

Benzodiazepine Rationale: They help prevent seizures and calm vital signs

A client is admitted to a psychiatric unit with the diagnosis of schizophrenia, undifferentiated type. When assessing the client, the nurse identifies the presence of several characteristics related to this disorder. What may this include? Select all that apply.

Bizarre behavior Disorganized speech Auditory hallucinations Rationale: Extreme negativity is associated with catatonic and persecutory delusions are associated with paranoid

Which drugs may lead to a prolongation of the QT interval in a client who is on drug therapy for schizophrenia? Select all that apply.

Haloperidol Thioridazine Chlorpromazine Rationale: Prolongation of the QT interval indicates severe dysrhythmias

A client diagnosed with depression is prescribed phenelzine. Which foods, if consumed along with this drug, may cause a hypertensive crisis? Select all that apply.

Red wine Aged meat Aged cheese Rationale: MAOIs may cause HTN crisis if consumes foods rich in tyramine

What is the planned effect of naloxone when it is administered for a heroin overdose?

To compete with opioids for occupancy of opioid receptors Rationale: Naloxone is used to treat opioid-induced apnea by competing with opioids for CNS system receptor sites

While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse?

"I'd like to understand what you're saying, but I'm having difficulty following you." Rationale: Lets the client know the nurse is trying, increases their self-esteem and points out reality

One morning a client with the diagnosis of schizophrenia claims to be Joan of Arc about to be burned at the stake. What is the most therapeutic response by the nurse?

"It seems like the world is a pretty scary place for you. Rationale: Attempting to understand symbolism, reflects the feelings and preserves their integrity

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk?

"It's time for you to go for a walk now." Rationale: Concise and doesn't require decision-making and is least likely to increase anxiety

A client with the diagnosis of schizophrenia, paranoid type, is admitted to the hospital. The client says to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere!" What is the most therapeutic response by the nurse?

"You don't feel safe anywhere, not even in the hospital?" Rationale: Facilitates further communication, allows the nurse to be understanding and doesn't belittle the client's feelings

A client with a diagnosis of bipolar I disorder, manic episode, is started on a regimen of an antipsychotic agent and lithium carbonate. The nurse explains to the client that the rationale behind this regimen is that the antipsychotic has which action?

Acts to quiet the client while allowing time for the lithium to reach a therapeutic level Rationale: Antipsychotics are usually prescribed in agitated clients in the 3 week period it takes for lithium to become effective

A client with a long history of alcohol abuse develops acute pancreatitis. What should be done to best prevent stimulation of the pancreas?

Administer the histamine H2-receptor antagonist as prescribed. Rationale: This inhibits H2 receptor sites in parietal cells which decreases gastric secretion, preventing pancreatic stimulation

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs?

Allow the client to undress when ready to help maintain identity. Rationale: This is the only response that doesn't increase anxiety and avoids a confrontation

What are the priority nursing interventions for a grieving client? Select all that apply.

Allowing the client to express feelings Respecting the feelings of the client and creating a comfortable environment Rationale: Provide an environment that allows the client to express their feelings. Respect their privacy and need or desire to talk

A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply.

Appearing disheveled Staying alone in the house Exhibiting indifference to family activities Rationale: No interest in completing ADL's, social isolation is a sign of mental illness and lack of emotional energy

A primary healthcare provider prescribes an antidepressant for a hospitalized client who has been severely depressed. Eight days later the nurse notes that the client is neatly dressed and well groomed. The client smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the client's statement?

Arranging for constant supervision of the client Rationale: Change in behavior that seems positive may indicate the client has worked out a plan for suicide

A depressed client is admitted to the hospital after being found bleeding from a superficial self-inflicted gunshot wound. The client does not respond to any of the nurse's questions. What should the nurse do to assess the client's current potential for suicide?

Ask the family about any recent suicide attempts or threats by the client. Rationale: Conclusions about scars may not be accurate

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion?

Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Rationale: Opioids cause CNS depression

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of what?

Grandeur Rationale: During a manic episode, a client has an inflated self-esteem that replaces feelings with which the client cannot cope

After treatment, an adolescent with a history of schizophrenia improves and is to be discharged. The parents tell the nurse that they are concerned about how to respond "if our child starts to act crazy." What is the most therapeutic response by the nurse?

Having the parents discuss mutual concerns with their child before the discharge date Rationale: This increases trust and fosters a good relationship

A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Select all that apply.

Insomnia Irritability Financial irresponsibility Rationale: Decreased need for sleep, primary mood is irritability and impulsivity are common

A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?

Intramuscular injections of thiamine Rationale: Thiamine is a coenzyme needed for production of energy from glucose

For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply.

Irritability Tachycardia Increasing anxiety Rationale: Alcohol is a CNS depressant

A client with psychosis is receiving olanzapine. What special information about this drug does the nurse recall?

It dissolves instantly after oral administration. Rationale: It's an oral disintegrating tablet and it'll instantly dissolve in contact with moisture

An extremely agitated client hospitalized in a mental health unit begins to pace around the dayroom. What should the nurse do?

Let the client pace in the hall away from other clients. Rationale: This allows the patient to work off energy away from other clients

The nurse cares for a client with schizophrenia and who is receiving ziprasidone. Which conditions in the client may indicate discontinuation of the drug? Select all that apply.

Leukopenia Hypokalemia Prolonged QT interval

The nurse provides care for a client with a long history of alcohol abuse. Which drug does the nurse anticipate will be prescribed for the client to prevent symptoms of withdrawal?

Lorazepam Rationale: It's most effective in preventing signs and symptoms associated with withdrawal

A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when the client states that what is one major disadvantage of ECT?

Memory is impaired after the treatment. Rationale: This is usually a side effect

A nurse assesses a client recently admitted to an alcohol detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification?

Nausea Rationale: Nausea and anorexia are expected

A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client?

Neuroleptic malignant syndrome Rationale: Symptoms are fever and unstable BP

Thiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan?

Neuronal activity Rationale: These vitamins help convert glucose for energy

A client is diagnosed with acute mania. The primary healthcare provider plans to prescribe lithium therapy to the client. After assessing the client's condition, the primary healthcare provider changes the therapy. Which client conditions would cause the provider to change course? Select all that apply.

Pregnancy Atherosclerosis Renal insufficiency Sever dehydration Rationale: CV diseases increase lithium toxicity. Dehydration causes electrolyte imbalance, it's contraindicated in clients with kidney problems and lithium may harm a fetus.

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response?

Saying, "I'll be back in a few minutes so we can talk." Rationale: This allows the client to regain self control

A 32-year-old client is hospitalized with a diagnosis of a bipolar disorder, manic episode. The client becomes loud and vulgar and disturbs the other clients. What is the best reaction by the nurse to this situation?

Segregating the client until this phase of the illness passes Rationale: During the manic phase, when clients are unable to control their behavior, they should be protected from embarrassing themselves or harming others' feelings

A client consumes alcohol during pregnancy. Which condition does the nurse anticipate to be seen in the newborn?

Stillbirth Rationale: Heart defects occur in the new born when the mom is exposed to antimicrobials and anti seizure drugs cause growth delays. Multiple defects may be seen in a child who's mother was exposed to vit. a derivatives

Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?

Suspicious feelings Rationale: Establish a basic trust

A client is responding within 5 minutes of receiving naloxone to combat respiratory depression from an overdose of heroin. Why will a nurse continue to closely monitor this client's status?

Symptoms of the heroin overdose may return after the naloxone is metabolized. Rationale: When naloxone has been metabolized, respiratory distress from overdose often returns

A client with a long history of alcohol abuse who has been hospitalized for 1 week tells the nurse, "I feel much better and probably won't need any more treatment." What does the nurse conclude when evaluating the client's progress?

The client's lack of insight into the emotional aspects of the illness indicates the need for continued supervision. Rationale: This statement indicates denial

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.

Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip

A woman who abused drugs during pregnancy gave birth to a drug-dependent neonate. Which nursing interventions would be beneficial to the neonate? Select all that apply.

To administer smaller doses of the dependent drug To monitor the neonate carefully and closely To educate the mother about the risks of drug abuse Rationale: Doses should be tapered to prevent withdrawal syndrome. They should be monitored carefully in case issues arise and mom should be educated to prevent further exposure

In addition to hydration during alcohol withdrawal delirium, parenteral administration of lorazepam is prescribed for a client. The nurse knows that this drug is given during detoxification primarily for what purpose?

To reduce the anxiety tremor state and prevent more serious withdrawal symptoms Rationale: Potentiates the actions of GABA which reduces anxiety and irritability

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Which data are the cause of the nurse's concern? Select all that apply.

Tremors in both hands make it difficult for the client to hold a cup. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television. Rationale: Agitation is a psychosocial characteristic and systolic BP would rise

A client with schizophrenia is observed sitting alone quietly talking. The client appears sad and is tearful. Place the following nursing assessment questions in the appropriate order to best ensure client safety.

1. "Are you hearing voices?" 2. "What are the voices telling you?" 3. "Are you thinking about hurting yourself or someone else?" 4. "What do you usually do to make the voices stop?"

A client with a history of alcohol abuse was admitted 2 days ago for treatment of a gastrointestinal bleed. The client has remained in bed; pulse rate and blood pressure has gradually increased. The client now has a low-grade fever. Place the following nursing interventions in the appropriate order to best minimize the client's risk for injury.

1. Initiate seizure precautions 2. Turn off the client's television and dim the room's lights 3. Attempt to determine when the client last consumed alcohol 4. Notify the primary healthcare provider of the report findings

Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Select all that apply.

Agitated behavior Delusions of grandeur Auditory hallucinations

When caring for a newly admitted depressed client, a nurse arranges for a staff member to remain with the client continuously. What information supports the nurse's decision to institute this precaution? Select all that apply.

Agitated pacing in the hall History of suicide attempts Statements that life is not worth living Rationale: Agitated clients are more likely to act impulsively, and clients who've attempted suicide or have thoughts are at greater risk

A client who is addicted to opioids undergoes emergency surgery. During the postoperative period the healthcare provider decreases the previously prescribed methadone dosage. For what clinical manifestations will the nurse monitor the client?

Agitation and attempts to escape from the hospital Rationale: Craving for opioids may occur when dosage is reduced which will increase anxiety and agitation

A 19-year-old adolescent is admitted to the emergency department with multiple fractures and potential internal injuries. The client's history reveals multiple drug abuse for the past 8 months. When caring for this client, the nurse determines that the most serious life-threatening responses usually result from withdrawal from which drug?

Barbiturates Rationale: Withdrawal from CNS depressants is associated with more severe morbidity and mortality

A client who is on haloperidol therapy has developed akathisia and acute dystonia. Which drugs would be used to manage extrapyramidal effects? Select all that apply.

Benztropine Trihexyphenidyl Rationale: Benztropine and trihexyphenidyl are anticholinergic drugs used to treat EPS

A client has been receiving oxycodone for moderate pain associated with multiple injuries sustained in a motor vehicle collision. The client has returned three times for refills of the prescription. Which assessment finding, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication?

Constricted pupils Rationale: Pupil constriction is a physical sign of opioid OD

The nurse is reviewing the Alcohol Use Disorders Identification Test (AUDIT) reports of four clients. Which client requires highest priority for treatment?

D Rationale: A score o 3 for all the questions indicates severe alcohol abuse

What medication does the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil Rationale: Competitively inhibits activity at benzodiazepine recognition sites on GABA receptor complexes

A client with a history of methamphetamine use is admitted to the medical unit. What clinical manifestation does the nurse expect when assessing the client?

Increased heart rate Rationale: Methamphetamine is a stimulant which activates the CNS

A client with a history of alcohol abuse was admitted 2 days ago for treatment of a gastrointestinal bleed. The client has remained in bed; pulse rate and blood pressure has gradually increased. The client now has a low-grade fever. Place the following nursing interventions in the appropriate order to best minimize the client's risk for injury.

Initiate seizure precautions Turn off the client's television and dim the room's lights Attempt to determine when the client last consumed alcohol Notify the primary healthcare provider of the report findings

A client has been in the alcohol detoxification unit for 5 days. In the evening the client complains of numbness and tingling in the feet and legs. What is the most appropriate nursing intervention?

Keeping the bed linens off the client's legs with a mechanical aid Rationale: Peripheral neuropathy is present and keeping the bed linens off will limit the tactile stimulation

The nurse cares for a client diagnosed with bipolar disorder who was prescribed drug therapy. Laboratory reports reveal that the client's thyroxine levels are low. Which drug might have led to this condition?

Lithium Rationale: It's the only medication used to treat bipolar disorder

A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?

Loosened associations and hallucinations Rationale: These are primary behaviors associated with a thought disorder

A nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana? Select all that apply.

Lung cancer Emphysema Heart disease Rationale: Laryngeal disorders, stroke and nasal irritation are associated with the abuse of cocaine

An adolescent has pinpoint pupils, respiratory depression, and cyanosis. Upon assessment, the school nurse observes needle marks on arms and legs. Which drug is the adolescent probably abusing?

Narcotics Rationale: Opioids are grouped under narcotics

A nurse is counseling a client who is experiencing substance abuse delirium. What communication strategies should be used by the nurse when working with this client?

Offering an introduction to the client at each meeting Rationale: Clients with delirium have short term memory loss

The primary healthcare provider notices that a client exhibits a period of mania followed by hypomania and depression and prescribes lithium carbonate. What is the mode of administration of the prescribed drug?

Oral route Rationale: Should only be administered via oral route

What factors may cause an adolescent to develop a smoking addiction? Select all that apply.

Peer pressure Imitating adult behavior of smoking Imitating lifestyles portrayed in movies and advertisements

A person who is hospitalized for alcoholism becomes boisterous, belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse?

Sedating and placing the client in a controlled environment Rationale: Out of control and acts as a danger to others. Safety requires safety and a controlled environment

The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply.

Sedation Respiratory rate Rationale: Chronic use of opioids for pain may lead to constipation, nausea, vomiting, sedation and respiratory distress

While caring for a client on antidepressant therapy, the nurse observes hyperthermia and seizures. Upon a further assessment, the nurse finds that the client's heart rate is 200 beats per minute. Which medication might be responsible for the condition?

Sertraline Rationale: Cardiac dysrhythmias on a client with serotonin syndrome

A client is hospitalized for a bipolar mood disorder, manic episode. The client is hyperactive and obnoxious, calls the nurse names, is sarcastic to the staff, and taps the nurse playfully on the buttocks. What is the most important action of the nurse?

Set limits for unacceptable behavior Rationale: The first step should be to set limits to maintain the client's dignity and prevent escalation of inappropriate behavior

A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client?

Sleep will be induced and the treatment will not cause pain. Rationale: Clients fear it will be painful. This reduces anxiety

A client with a history of excessive alcohol use develops hepatic portal hypertension and an elevated serum aldosterone level. For which complications should the nurse assess this client?

Sodium retention and fluid accumulation Rationale: Aldosterone causes sodium and water retention and potassium excretion by the kidneys

A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication?

Switches the user from illicit opioid use to use of a legal drug Rationale: Methadone may be dispensed legally

A client with paranoid schizophrenia wraps the legs in toilet paper, believing that this will provide protection from deadly germs contaminating the floor. What is the best nursing intervention?

Talking with the client about anxiety that focuses on health Rationale: Exploring the feelings of the delusions are more therapeutic than discussing content

A male client with the diagnosis of schizophrenia, paranoid type, often displays overt sexual behavior toward female clients and nurses. What is the nurse's best response when the client engages in sexually explicit behavior?

Telling the client in a matter-of-fact manner that his behavior is unacceptable Rationale: This rejects the behavior not the client

During a nursing team conference, a mental health worker suggests that a client with schizophrenia, paranoid type, be assigned to group therapy. What should the nurse manager explain about this type of therapy for this client?

Therapeutic group work tends to be threatening to individuals who are suspicious. Rationale: Unable to tolerate the give-and-take necessary for a successful group

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon?

Tolerance Rationale: Increasing amounts of the drug are needed to have an effect

A client undergoing alcohol detoxification asks about attending Alcoholics Anonymous (AA) meetings after discharge. What is the nurse's best initial reply?

"How do you feel about going to those meetings?" Rationale: This focuses on the client's feelings rather than the organization itself

After an automobile accident a person is arrested for driving while intoxicated and is admitted to the hospital. When the client becomes angry and blames the family for personal problems, the nurse can be most therapeutic by using which statement?

"I can see that you're upset about your family, but we need to focus on what you need right now." Rationale: This focuses on the client's feelings with a supportive, helpful approach

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse?

"I didn't hear anyone talking; come with me to your room." Rationale: Focus on reality and refocus the client's attention

A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response?

"I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?" Rationale: This validates the presence of the client's hallucinations without agreeing and can be interpreted as acceptance and may help the client return to reality

A client with schizophrenia is going to occupational therapy for the first time. The client doesn't want to go and tells the nurse so. What is the most therapeutic initial response by the nurse?

"Tell me what concerns you about going to occupational therapy." Rationale: It's an open ended statement allowing the nurse to explore patient's concerns

Two days after admission to the detoxification program, a client with a long history of alcohol abuse tells the nurse, "I don't know why I came here." What is the most therapeutic response by the nurse?

"You feel that you don't need this program?" Rationale: Identifies the feeling of ambivalence associated with admitting they have a problem with alcohol

After a week on the mental health unit, a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are." What is the best response by the nurse?

"You're having very frightening thoughts." Rationale: Reflects the clients feelings and leaves line of communication open

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group?

Changing destructive behavior

A 45-year-old client who recently completed alcohol detoxification reports plans to begin using disulfiram (Antabuse) as part of the alcoholism treatment regimen. What important client teaching does the nurse share regarding this drug?

Foods, medications, and any topical preparation containing alcohol should be avoided. Rationale: Can cause unpleasant physical effects when mixed with alcohol