MH Learning Systems Wrong Answer

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired is an important part of your treatment" B. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow" C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way" D. "I agree with your decision to wait for participation in group therapy until you begin to feel better"

A. "Attending group therapy, even if you're tired is an important part of your treatment" (through this therapeutic response, the nurse is giving the client information to make an informed decision. Group therapy benefits clients who have depression by promoting peer support and reducing social isolation)

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect? A. "I pick my face when I am nervous" B. "I have bald patches from pulling out my hair" C. "I inspect my body in the mirror several times a day" D. "I am unable to part with any of my belongings"

A. "I pick my face when I am nervous" (The nurse should recognize that this statement is an indication of excoriation disorder. Clients who have excoriation disorder typically pick their faces when experiencing stress or anxiety)

A nurse is reinforcing teaching with the parents of a school-aged child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? A. "Ignore your child's attention-seeking behaviors that are not dangerous" B. "Administer ADHD medications within 30 mins of your child's bedtime C. "Continue with an activity as planned even if your child becomes frustrated" D. "Expect your child to gain weight after starting ADHD medications."

A. "Ignore your child's attention-seeking behaviors that are not dangerous" (The nurse should instruct the parents about the use of planned ignoring. This technique ignores attention seeking behaviors that are not dangerous to the child or others. If the child learns that the behavior will not elicit the desired response, then the behavior should decrease)

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurse's priority? A. Ask the client what the voices are saying B. Focus the client's attention on reality-based activities C. Make eye contact when speaking with the client D. Encourage the client to listen to music through headphones

A. Ask the client what the voices are saying (the greatest risk for this client is an injury to self or others due to command hallucinations. Command hallucinations can be a psychiatric emergency. Therefore, the nurse priority is to ask the client what the voices are saying.)

A nurse is assisting with planning of a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nurse include during the orientation phase of group development? A. Determine the rules that the group will follow B. Address disagreements among group members C. Help clients work through the grief D. Transition from role of the leader to facilitator

A. Determine the rules that the group will follow (During the orientation phase of group development, the nurse should determine the rules that apply to the group and ensure that all members understand these rules. Examples of rules to be discussed include confidentiality and meeting times)

A nurse is collecting data from a client who takes an MAOI for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? A. Elevated BP B. Weight gain C. muscle twitching D. 2+ pitting edema

A. Elevated BP (increases risk of hypertensive crisis)

A nurse in an assisted living facility is collecting data on an older adult client. Which of the following findings should the nurse identify as expected age-related changes? A. Forgetting the day of the week B. Challenges with problem-solving C. Decreased judgment D. Withdrawal from social activities

A. Forgetting the day of the week (The nurse should identify that forgetting the day of the week and remembering it later is an expected age-related change in older adult clients. Other findings can include needing assistance when operating devices such as a microwave, making occasional errors when balancing a checkbook, having difficulty finding the correct use of a word, and becoming tired after family gatherings or social activities)

A nurse is collecting data from a newly admitted client. To establish trust, which of the following actions should the nurse perform during the orientation phase of the nurse-client relationship? A. Inform the client that the admission is confidential B. Introduces the client to other clients in the dayroom C. Assist the client with facilitating behavioral change D. Determine coping strategies that the client has used in the past

A. Inform the client that the admission is confidential (According to evidence-based practice, the nurse should inform the client about confidentiality during the orientation phase of the nurse-client relationship. This action helps establish trust between the nurse and the client.)

A nurse is collecting data from a client prior to the administration of lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4lb) since the start of treatment C. Fine tremors present in both hands. D. Serum lithium level of 1.1 mEq/L

A. Report of nausea with frequent episodes of emesis (the nurse should identify that gastrointestinal upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. The nurse should check the client for indications of dehydration, which further increases the risk of lithium toxicity)

A nurse is collecting data from a client who has bipolar disorder and is in a manic state. Which of the following findings is the highest priority? A. The client reports sleeping 2 to 3 hours per night B. The client speaks to the nurse in a demanding tone C. The client reports not attending group therapy D. The client reports not taking medication for the past 2 weeks.

A. The client reports sleeping 2 to 3 hours per night (the greatest risk to this client is an injury from exhaustion due to lack of sleep; therefore, the priority finding is the client's report of decreasing sleep time)

A nurse is caring for a client who has schizophrenia and states, "My doctor is trying to kill me." Which of the following responses should the nurse make? A. "Why would you say that your doctor is trying to kill you?" B. "It must be frightening to feel that your doctor is trying to kill you" C. "Your doctor wants to help you, not kill you D. "How long has your doctor been trying to kill you?"

B. "It must be frightening to feel that your doctor is trying to kill you" (When a client is experiencing a delusion, the nurse should empathize with the feelings behind the client's delusion)

A nurse in a community mental health facility is caring for a group of clients should the nurse identify as experiencing an adventitious crisis? A. A client who has a new diagnosis of severe bipolar disorder B. A client who is depressed following a devastating fire in her home C. A client who is experiencing acute grief following his father's death D. A client who is experiencing postpartum depression following the birth of her first child

B. A client who is depressed following a devastating fire in her home (the nurse should identify that a client who is experiencing depression following a house fire is experiencing an adventitious crisis. An adventitious crisis is unplanned and not a part of everyday life. The crisis can result from a natural disaster, a national disaster, or crime of violence)

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A. Actual loss B. Maturational loss C. Perceived loss D. Situational loss

B. Maturational loss (A maturational loss is tied to a normal, expected life change) A. An actual loss occurs when a person can no longer interact with a loved one or losses a job or a precious item. C. A perceived loss is less obvious to those around an individual D. A situational loss is sudden and unpredictable

A nurse is reinforcing teaching with the caregiver of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Offer the client a list of activities to choose from B. Offer finger foods to the client C. Discourage naps throughout the day D. Turn on the television when the client is in the room

B. Offer finger foods to the client (The caregiver should offer finger foods that the client can eat without sitting down. Clients who has dementia often like to wander and walk off nervous energy, which can decrease anxiety and calm the client)

A nurse is reinforcing teaching with a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should reinforce with the client that TMS can cause which of the following? A. Retrograde amnesia B. Seizures C. Confusion D. Suicidal ideation

B. Seizures (Although uncommon, seizures are a potential adverse effect of TMS)

A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the client's risk of which of the following adverse effects? A. Increased intracranial pressure B. Serotonin syndrome C. Acute kidney function D. Hypertensive crisis

B. Serotonin syndrome (Serotonin syndrome is a toxic effect that can occur from taking an MAOI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability; these can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction.)

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? A. "Her mannerologies are poor" B. "My dog blank a boat to supreme heights" C. "I can play the flute while wearing a suit. You are cute" D. "My joints ache. My friend is in the joint"

C. "I can play the flute while wearing a suit. You are cute" (The nurse should recognize this statement is an example of clang association. Clang association refers to the use of words that are based on sound rather than meaning. A client who has schizophrenia will often use words that rhyme or have a similar beginning sound)

A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A. "A tornado is going to wipe us all out in 9 days" B. "My brain is dead, and my body is slowly rotting away." C. "The government is after me because I Know top secret information" D. "The TV is purposely playing commercials for things I don't like"

C. "The government is after me because I Know top secret information" (The nurse should identify this statement as an indication of a persecutory delusion)

A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client? A. CAGE assessment B. Hamilton Anxiety Rating Scale C. Abnormal Involuntary Movement Scale (AIMS) D. SAFE-T Tool

C. Abnormal Involuntary Movement Scale (AIMS) (The AIMS is an assessment tool that identifies and tracks involuntary movements in clients who have tardive dyskinesia) A. The CAGE (Cut Annoyed Guilty Eye-opener) assessment is used to diagnose alcohol use disorder B. The Hamilton Anxiety Rating Scale is used to measure psychological distress and physical symptoms associated with anxiety. D. The SAFE-T (Suicide Assessment Five-step Evaluation and Triage) tool is used to assess a client's risk factors for suicide

A nurse is reinforcing teaching with a client who has a new prescription for lorazepam to treat alcohol withdrawal. Which of the following should the nurse identify as an adverse effect of lorazepam that the client should report to the provider? A. Increased thirst B. Sweating C. Blurred vision D. facial flushing

C. Blurred vision (The nurse should inform the client that blurred vision is an adverse effect of lorazepam and instruct the client to notify the provider if this occurs)

A nurse is planning care for a client who is experiencing complicated grief following the unexpected death of his partner. Which of the following actions should the nurse plan to take first? A. Positively reinforce new coping skills that increase the client's self-esteem B. Encourage the client to seek support from a counselor who specializes in grief C. Determine which stage of grief the client is experiencing D. Allow the client to express angry feelings associated with the grief

C. Determine which stage of grief the client is experiencing (The first action the nurse should take using the nursing process to collect data to determine the stage of grief the client is fixed in to establish a baseline from which to plan care)

A nurse is reviewing discipline technique with the parents of an adolescent client who has oppositional defiant disorder. Which of the following techniques should the nurse recommend as an effective method of responding to the adolescent? A. Offering frequent physical touching B. Allowing self-regulation of boundaries C. Practicing planned ignoring D. Giving negative feedback

C. Practicing planned ignoring (Planned ignoring is an appropriate means of responding to clients who have oppositional defiant disorder. The nurse should reinforce the use of this technique with the parents as a response to the client's attention-seeking behaviors)

A nurse on a mental health unit is planning care for a client who has anorexia nervosa with purging behaviors. Which of the following interventions should the nurse include in the plan? A. Set the client's weight gain goal at 2.3 kg (5 lb) per week B. Allow the client to establish his own mealtimes. C. Stay with the client for a hour following meals. D. Have the client weigh himself daily

C. Stay with the client for a hour following meals. (The nurse should plan to stay with and observe the client for 1 hour following each meal to discourage the client from hiding food or purging by self-induced vomiting) (ANSWER I CHOSE) D. The nurse should plan to weigh the client in the morning immediately following the first voiding while the client is wearing underwear. The nurse should use the same scale each day to obtain the weight measurement to ensure accuracy. The client's daily weight will guide the treatment plan. The client may wish to not look at or be told his weight)

A nurse in a provider's office is collecting data from a client who has been taking varenicline. Which of the following reports from the client indicate a therapeutic response to the medication? A. The client is taking fewer opioid pain relievers B. the client no longer has delirium tremens C. The client has reduced cravings for cigarettes. D. the client is less hyperactive

C. The client has reduced cravings for cigarettes. (Varenicline is prescribed for the treatment of tobacco use disorder. A therapeutic response to the medications prescribed for this disorder include bupropion and clonidine)

A nurse is collecting data from a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Arthralgia B. Photophobia C. Xerostomia D. Bradycardia

C. Xerostomia (buspirone can cause xerostomia, or dry mouth. Other adverse effects include headache, nausea, and insomnia)

A nurse is reinforcing teaching with a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching? A. "If I fail to stop smoking after 12 weeks, I will try another product" B. "I will take the medication for 7 days before i try to stop smoking" C. "This medication will cause me to lose weight as I stop smoking." D. "I will take the medication after eating a meal."

D. "I will take the medication after eating a meal." (The nurse should instruct the client that taking varenicline following a meal with a full glass of water will minimize the associated nausea)

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A. "Can you tell my why you do not want to participate in the planned group activity? B. "Do you understand that psychotropic medications cause weight gain?" C. "The aerobics class will be more effective at burning calories than walking" D. "It sounds like you have come up with an alternative exercise that works for you"

D. "It sounds like you have come up with an alternative exercise that works for you" (The nurse is using therapeutic techniques of acceptance, giving recognition, and encouragement by supporting the client's idea of a way to exercise)

A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." A. "Aliens do not exist" B. "Has your daughter had her baby?" C. "Do you mean to say a laboratory technician drew your blood last night?" D. "That does not sound real"

D. "That does not sound real" (The nurse is voicing doubt with this response, which expresses uncertainty regarding the reality of the client's conclusion of the hallucination. This is a therapeutic response because the statement allows the client to expand upon the earlier statement, which allows exploration of the client's thought processes)

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. Blurred vision B. Urinary Retention C. Muscle flaccidity D. Elevated temperature

D. Elevated temperature (this is a manifestation of neuroleptic malignant syndrome that should be immediately reported to the provider. Other symptoms of the syndrome include rigidity, sweating, dysrhythmias, and fluctuations in BP)

A nurse is preparing to care for a client who was brought to a community health facility by the caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take? A. Make sure the caregiver is present when interviewing the client B. Document how the caregiver responds when told that the client looks neglected C. Ask the client why she refuses to eat the caregiver's food D. Identify sources of stress for the caregiver

D. Identify sources of stress for the caregiver (In addition to collecting information from the client, the nurse should interview the caregiver and should ask about sources of stress. It is important to gain an understanding of the social environment of the home to identify needed changes that may improve care for the client)

A nurse is assisting with care of a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse prepare to administer? A. Carbamazepine B. Clonidine C. Propranolol D. Lorazepam

D. Lorazepam (The nurse should expect to administer lorazepam, a benzodiazepine, as the first treatment for acute withdrawal. Along with decreasing symptoms of acute alcohol withdrawal, these medications can also maintain vital signs and prevent seizures and delirium tremens)

A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem-solving skills B. Understanding the medication regimen C. Identifying indications of relapse. D. Maintaining adequate hydration

D. Maintaining adequate hydration

A nurse is collecting data from a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline? A. Disorientation to time B. Problems handling finances C. Social withdrawal D. impaired recent memory

D. impaired recent memory (short term memory loss is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality)

A nurse is leading a group therapy session for a group of clients. Which of the following client statements should indicate to the nurse that the client is using the defense mechanism of rationalization? A. "I became a team manager because I'm not tall enough to succeed at basketball" B. "I don't want to talk right now about the fire that destroyed my home" C. "I take amphetamines because it's the only way I can keep up with all the studying for my classes." D. "I will spend a day cleaning my house when I feel like my life is out of control"

Rationalization is the act of justifying unacceptable thoughts or behaviors with a seemingly acceptable explanation. Rationalization allows the client to protect the ego and avoid taking responsibility for actions or thoughts that can cause shame or embarrassment)