NR 326 CMS Exam
Which of the following statements indicates that the client is at risk for complicated grief?
"I feel so empty without my wife that it's hard to get up every morning." The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief.
A client is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?
Acute dystonia.
Findings of anorexia nervosa
Amenorrhea Lanugo Cold extremities
What are interventions for olanzapine?
Avoid driving during initial therapy due to drowsiness and dizziness. Take frequent sips of water for dry mouth. Consult a dietician and exercise regularly to help manage weight gain.
Manifestations of PTSD
Avoidance; difficulty sleeping and hypervigilance; experiences feelings of isolation; verbal aggression
Which of the following clients can give informed consent? A. A 17-year-old client who lives with friends B. A 50-year-old client who has a BAC of 80 mg/dL C. A 35-year-old client who has major depressive disorder D. A 65-year-old who just received a dose of morphine
C. A 35-year-old client who has major depressive disorder. A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent
Nurse John is aware that most crisis situations should resolve in about: A. 1-2 weeks B. 4-6 weeks C. 4-6 months D. 6-12 months
CORRECT - Option B: Crisis is self-limiting and lasts from 4 to 6 weeks.
What are findings for a patient who recently used cocaine
Cocaine is a stimulant that increases BP. It also inc. HR, body temp, energy levels, and metabolism
A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others.
Command hallucinations. A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others.
Adverse effects of fluoxetine
Dry mouth Sexual dysfunction (anorgasmia and impotence) Visual disturbances
A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?
Establish screening programs to identify at-risk patients. This is an example of secondary prevention.
When should prescriptions for restraints be renewed?
Every 4 hours for a maximum of 24 hr
A client has alcohol toxicity and is unresponsive, what is an appropriate nursing intrevention?
Gather supplies for an endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.
A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?
Giving away possessions. This indicates that this client is at greatest risk for suicide.
Lab values for a client with alcoholic cardiomyopathy
Increased creatine phosphokinase
Manifestations of opioid withdrawal
Insomnia; rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain; tachycardia; hyperthermia
Manifestations of anorexia nervosa
Orthostatic hypotension Bradycardia Amenorrhea Constipation
What is an example of the ethical principle of veracity?
Providing a client with accurate information about their prognosis
A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?
Reduce environmental stimuli. The greatest risk to the child and others is harm. Therefore, the nurses priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.
What are nursing interventions for a client having a panic attack?
Remain with the client to ensure safety. Assist the client with deep breathing techniques such as deep, abdominal breathing exercises.
What is an example of the ethical principle of justice?
Spending adequate time with a client who is verbally abusive. All clients should receive equal care.
What is succinylcholine given for during ECT therapy?
Succinylcholine is given to reduce muscle movements during therapy so that the client is less likely to be injured
A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?
Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child.
A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?
Tachycardia Dry mouth Weight loss
A patient has schizophrenia and is experiencing psychosis. Which of the following findings indicates a potential psychiatric emergency?
Thee client reports command hallucinations. These can direct thee client to harm themselves or others.
A client has anorexia nervosa, what finding requires hospitalization?
Total body fat 8.7%. The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat.
What lab values are a contraindication for receiving clozapine?
WBC count 2,500/mm3 Clozapine can cause agranulocytosis. A WBC count of less than 3,000/mm3 should be identified as a possible manifestation of agranulocytosis. Withhold the med and notify HCP.
A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who is experiencing delusions of persecution. This indicates that the client is at greatest risk for injury due to the client's belief that a person in power is out to harm them.
When conducting a suicide risk assessment, the nurse considers the following risk factors (select all that apply): A.Age B.Religion C.Gender D.City E.Family history
A. Age C. Gender E. Family History
Ben is teaching a patient who is prescribed lithium for bipolar disorder, the early indications of toxicity. Ben includes teaching to report the following to the physician (select all that apply): A.Constipation B.Polyuria C.Rash D.Muscle weakness E.Tinnitus
A. Constipation (Diarrhea- early indications) CORRECT - B. Polyuria (extreme polyuria of dilute urine= advanced) C. Rash CORRECT - D. Muscle weakness (common s/e) E.Tinnitus (advanced) CORRECT - F. Poor coordination (early indications)
Gene is a nurse administering lithium to patients with bipolar disorder. Gene knows that advanced level(s) of lithium toxicity is: A.2.0-2.5 mEq/L B.Less than 1.5 mEq/L C.1.5-2.0 mEq/L D.Greater than 2.5 mEq/L
A.2.0-2.5 mEq/L
Gina is assessing a patient 4 hours after administering a first dose of fluoxetine. Which of the following findings should Gina report to the provider as indications of serotonin syndrome? (Select all that apply): A.Agitation B.Diaphoresis C.Muscular flaccidity D.Hallucinations
A.Agitation B.Diaphoresis D.Hallucinations
A nurse has a patient who is taking paroxetine for posttraumatic stress disorder. The patient states that he grinds his teeth during the night, which causes pain in his mouth. The nurse identifies which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply) A.Concurrent administration of buspirone B.Administration of a different SSRI C.Use of a mouth guard D.Changing to a different class of antianxiety medication E.Increasing the dose of paroxetine
A.Concurrent administration of buspirone C.Use of a mouth guard D.Changing to a different class of antianxiety medication
An RN is caring for Betsy, a patient who recently experienced the death of her mother. The RN knows that the following factors influence the patient's grief and coping ability (select all that apply): A.Culture B.Birth order C.Spiritual beliefs D.Interpersonal relationships E.Prior experience with loss
A.Culture C.Spiritual beliefs D.Interpersonal relationships E.Prior experience with loss
Characteristics of a school-aged child with conduct disorder?
Aggression toward people and animals. Lack of remorse.
What is an example of the ethical principle of autonomy?
Allowing a client to choose which unit activities to attend
What treatment option offers interdisciplinary services for clients at home?
Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy
What is an example of the ethical principle of nonmaleficence?
Attempting alternative therapies instead of restraints for a client who is combative.
Chet is the nurse preparing to care for a patient consenting to electroconvulsive therapy (ECT). Chet knows that ECT considerations include the following (select all that apply): A. ECT treatment course is usually once a month for a total of two to three treatments B.An informed consent is necessary C. Thirty minutes before the procedure, IM Atropine Sulfate/glycopyrrolate is administered to decrease secretions and prevent bradycardia D. During the procedure, methohexital or propofol is given IV bolus, as a short-acting anesthetic E. A muscle relaxant, succinylcholine, is given to paralyze the muscles.
B. An informed consent is necessary C. Thirty minutes before the procedure, IM Atropine Sulfate/glycopyrrolate is administered to decrease secretions and prevent bradycardia D. During the procedure, methohexital or propofol is given IV bolus, as a short-acting anesthetic E. A muscle relaxant, succinylcholine, is given to paralyze the muscles.
Which of the following clients is the nurse required to report as a potential victim of abuse? A. A school-age child who has bruises on the knees B. An older adult client who is bedbound and has a stage IV pressure ulcer C. An adolescent who has a vaginal candida infection D. A young adult who is pregnant and has a sprained ankle
B. An older adult client who is bedbound and has a stage IV pressure ulcer. This can indicate physical neglect and warrants mandatory reporting
A nurse assigned to care for a patient scheduled for electroconvulsive therapy (ECT) is aware of the following: A.Patients are expected to be alert an hour following ECT, offer fluids immediately upon awakening, monitor possible hypotension and tachycardia after ECT procedure B.Patients are expected to have short term memory loss, IV line is maintained until full recovery, monitor for possible hypertension and bradycardia after ECT procedure C.Patients are expected to have permanent memory loss, maintain indwelling catheter due to frequent urination, monitor for tonic-clonic seizure activity associated after ECT procedure D.Patients are expected to have relief of depressed moods two weeks after ECT, oxygen via nasal cannula will be maintained for one day, monitor for possible ECG changes and fever
B. Patients are expected to have short term memory loss, IV line is maintained until full recovery, monitor for possible hypertension and bradycardia after ECT procedure
Carbamazepine nursing education includes teaching the patient which of the following: A. Report skin rashes, severe GI effects, and wear sunscreen B. Report nystagmus, staggering gait, fever and lethargy C. Report polyuria, tinnitus, and constipation D. Report increased mania, restless legs, racing heartbeat
B. Report nystagmus, staggering gait, fever and lethargy
A patient is admitted to a psychiatric unit, demonstrating extreme mania due to bipolar disorder. Before administration of lithium carbonate, the patient's lithium blood level is 1.2 mEq/L. What is the nurse's priority of action? A.Prepare to administer aminophylline B.Administer the next dose of lithium carbonate as scheduled C.Notify the provider for a possible increase in the dosage of lithium carbonate D.Request a stat repeat of the patient's lithium carbonate, as ordered
B.Administer the next dose of lithium carbonate as scheduled
A patient who frequently seeks medical care and constantly asks the nurse to have her provider order excessive lab tests that are not necessary. The patient has been preoccupied for more than 6 months with excessive anxiety that a serious illness is present, or will be acquired. The patient's nurse understands that this is consistent with the following disorder: A.Somatic symptom disorder B.Conversion disorder C.Illness anxiety disorder D.Factitious disorder
C. Illness anxiety disorder
Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following? A. A warning about the drug's delayed therapeutic effect, which is from 14-30 days B. A warning about the incidence of neuroleptic malignant syndrome (NMS) C. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug D. A warning that immediate sedation can occur with a resultant drop in pulse
CORRECT - Option A: The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Option B: NMS hasn't been reported with this drug, but tachycardia is frequently reported. Option C: Blood level checks aren't necessary
Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior? A. By designating times during which the client can focus on the behavior B. By urging the client to reduce the frequency of the behavior as rapidly as possible C. By calling attention to, or attempting to prevent the behavior D. By discouraging the client from verbalizing anxieties
CORRECT - Option A: The nurse should designate times during which the client can focus on the compulsive behavior or obsessive thoughts. Option B: The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. Option C: She shouldn't call attention to, or try to prevent the behavior. Trying to prevent the behavior may cause pain and terror to the client. Option D: The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior.
The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be aware that the teaching about the side effects of this drug were understood when the client state, "I will call my doctor immediately if I notice any: A. Fine hand tremors or slurred speech B. Sensitivity to bright light or sun C. Sexual dysfunction or breast enlargement D. Inability to urinate or difficulty when urinating
CORRECT - Option A: These are common side effects of lithium carbonate.
Which medications have been found to help reduce or eliminate panic attacks? A. Antidepressants B. Anticholinergics C. Antipsychotics D. Mood stabilizers
CORRECT - Option A: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks isn't clearly understood. Option B: Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms of anxiety but don't relieve the anxiety itself. Option C: Antipsychotic drugs are inappropriate because clients who experience panic attacks aren't psychotic. Option D: Mood stabilizers aren't indicated because panic attacks are rarely associated with mood changes.
A 65 years old client is in the first stage of Alzheimer's disease. Nurse Patricia should plan to focus this client's care on: A. Offering nourishing finger foods to help maintain the client's optimal nutritional status. B. Providing emotional support and individual counseling. C. Monitoring the client to prevent minor illnesses from turning into major problems. D. Suggesting new activities for the client and family to do together.
CORRECT - Option B: Clients in the first stage of Alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. Options A, C, and D: The other options are appropriate during the second stage of Alzheimer's disease when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition.
Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against: A. Driving at night B. Staying in the sun C. Ingesting wines and cheeses D. Taking medications containing aspirin
CORRECT - Option B: Haldol causes photosensitivity. Severe sunburn can occur on exposure to the sun.
Nicolas is experiencing hallucinations tells the nurse, "The voices are telling me I'm no good." The client asks if the nurse hears the voices. The most appropriate response by the nurse would be: A. "It is the voice of your conscience which only you can control." B. "No, I don't hear your voices, but I believe you can hear them." C. "The voices are coming from within you and only you can hear them." D. "Oh, the voices are a symptom of your illness, don't pay attention to them."
CORRECT - Option B: The nurse, demonstrating knowledge and understanding, accepts the client's perceptions even though they are hallucinatory.
Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food B. Control eating impulses C. Identify anxiety-causing situations D. Eat only three meals per day
CORRECT - Option C: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family and friends until the client begins to eat B. Provide privacy during meals C. Set up a strict eating plan for the client D. Encourage the client to exercise, which will reduce her anxiety
CORRECT - Option C: Establishing a consistent eating plan and monitoring the client's weight are very important in this disorder. Option A: The family and friends should be included in the client's care. Option B: The client should be monitored during meals-not given privacy. Option D: Exercise must be limited and supervised.
Nurse Amy is providing care for a male client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: A. Barbiturates B. Amphetamines C. Methadone D. Benzodiazepines
CORRECT - Option C: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Options A, B, and D: Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.
The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent? A. Combativeness, sweating, and confusion B. Agitation, hyperactivity, and grandiose ideation C. Emotional lability, euphoria, and impaired memory D. Suspiciousness, dilated pupils, and increased blood pressure
CORRECT - Option C: Signs of antianxiety agent overdose include emotional lability, euphoria, and impaired memory. Option A: Phencyclidine (PCP) overdose can cause combativeness, sweating, and confusion. Option B: Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation. Option D: Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure.
Nurse Trina knows that the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD): A. Benztropine (Cogentin) and diphenhydramine (Benadryl) B. Chlordiazepoxide (Librium) and Diazepam (Valium) C. Fluvoxamine (Luvox) and Clomipramine (Anafril) D. Divalproex (Depakote) and Lithium (Lithobid)
CORRECT - Option C: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. Option B: Librium and Valium may be helpful in treating anxiety related to OCD but aren't drugs of choice to treat the illness. Options A and D: The other medications mentioned aren't effective in the treatment of OCD.
Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life threatening reaction: A.Tardive dyskinesia B. Dystonia C.Neuroleptic malignant syndrome D.Akathesia
CORRECT - Option C: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Option A: Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Option B: Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Option D: Akathisia causes restlessness, anxiety, and jitteriness.
Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks the nurse, "Why has this happened to me?" What is the nurse's best response? A. "You've developed this paralysis so you can stay with your parents. You must deal with the conflict if you want to walk again." B. "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical." C. "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life and why it's happened." D. "It isn't uncommon for someone with your personality to develop a conversion disorder during times of stress."
CORRECT - Option C: The nurse must be honest with the client by telling her that the paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The client will benefit from psychiatric treatment, which will help her understand the underlying cause of her symptoms. After the psychological conflict is resolved, her symptoms will disappear. Option A: Telling her that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict. Option B: Saying that it must be awful not to be able to move her legs wouldn't answer the client's question; knowing that the cause is psychological wouldn't necessarily make her feel better.
Which information is most important for the nurse Trinity to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)? A.Monthly blood tests will be necessary. B. Stop the medication when symptoms subside. C. Blood pressure must be monitored for hypertension. D.Report a sore throat or fever to the physician immediately.
CORRECT - Option D: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Option A: Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped. Option C: Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. Option B: The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
After seeking help at an outpatient mental health clinic, Ruby, who was raped while walking her dog, is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby? A. Recommending a high protein, low-fat diet B. Giving sleep medication, as prescribed, to restore a normal sleep-wake cycle C. Allowing the client time to heal D. Exploring the meaning of the traumatic event with the client
CORRECT - Option D: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. Option A: A special diet isn't indicated unless the client also has an eating disorder or a nutritional problem. Option B: The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate. Option C: The client must explore the meaning of the event and won't heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. Exposure therapy may also be indicated.
What are the rights of patients who are admitted involuntarily?
Clients who are admitted involuntarily maintain the right to refuse tx (including meds), to privacy and confidentiality, to give informed consent for tx
Janet is a nurse admitting a patient who recently experienced an attempted suicide. Janet knows that the facts about suicide include the following (select all that apply): A.Improvement after severe depression means that the suicidal risk is over. B.Clues and warnings about suicidal intentions are very subtle clues which may be ignored or disregarded by others C.Suicidal threats and gestures should be considered manipulative or attention-seeking behavior D.Gunshot wounds are the leading cause of death among suicide victims E.The majority of all people who ultimately kill themselves have a history of previous attempt.
D. Gunshot wounds are the leading cause of death among suicide victims E. The majority of all people who ultimately kill themselves have a history of previous attempt.
A school-aged child is taking atomoxetine, what adverse effect should the nurse report?
Dark urine. The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death.
What findings would indicate that a child is experiencing PTSD after the loss of a parent 8 months ago?
Detachment or estrangement from others. Difficulty sleeping and distressing dreams. Difficulty concentrating on tasks. Negative moods and difficulty remembering aspects of the traumatic event. Loss of interest or lack of participation in significant activities and events such as holidays.
A client is experiencing a headache and heart palpitations after having 1 glass of wine 1 hr ago. The client has a hx of depression and a BP of 210/105 mm Hg and a temp of 103.8 F. What action should the nurse take first?
Determine the client's prescribed medication regimen. This way the nurse can determine the cause of thee hypertension, such as the client taking mAOI to treat depression. These meds can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine.
What medication is administered first for a patient experiencing alcohol withdrawal?
Diazepam. The greatest risk to a client experiencing alcohol withdrawal is seizures, and elevated HR, and elevated BP. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations.
What are findings for a patient with borderline personality disorder?
Emotional lability. Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances.
What intervention should be included to promote sleep in a patient experiencing acute mania?
Encourage frequent rest periods throughout the day. Those experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion
Nursing interventions for a client with anorexia nervosa who is at 60% of ideal body weight
Encourage the client to drink 125 mL of fluid each waking hour to maintain hydration. Remain with the client during the duration of meals. For the first week of treatment, weigh the client daily upon waking, after voiding, and before eating or drinking. Measure vitals three times each day until the client's weight inc. and CV status improves.
A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?
Greater risk of attempting suicide as affect and energy improve. Constipation and paralytic ileus are possible adverse effects. Initial therapeutic response can take 1-3 weeks.
A nurse in a community health center is working with a group of clients who have PTSD. Which of the following interventions should the nurse include to reduce anxiety among the group members?
Guided Imagery. This involves assisting thee client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have PTSD.
A client with bipolar disorder stopped taking lithium 2 weeks ago. What adverse effect could have caused the the client to stop taking this medication?
Hand tremors. Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication
Manifestations of alcohol withdrawal
Hypertension, tachycardia, and fever greater than 101 F (be sure to rule out infection in a client who has a fever). Agitation, insomnia, irritability, profuse sweating, dilated pupils, hypoglycemia
A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?
Identify signs of escalation of violence.
Nursing interventions for a client with bulimia nervosa and is 5% over their ideal body weight
Identify the client's trigger foods and assist the client to understand their thoughts and behavior that relate to the food. Limit client's meal time to 30 mins. Weight the client immediately after they wake up and void and prior to oral intake.
A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider
Inability to sleep. Disorganized and chaotic behavior. Talking and joking incessantly and are highly interactive.
What findings of a patient taking lamotrigine should the nurse report?
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately
Manifestations of autism spectrum disorder
Language delay
Nursing interventions for a client with bipolar disorder and experiencing mania
Maintain a low-stimuli environment. Encourage the client to take frequent rest periods throughout the day. Frequently offer high-calorie foods that can bee eaten while the client is on the go. Encourage foods that are high in fiber.
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
Mild. The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.
A nurse is planning care for a client who is to undergo ECT. Which of the following actions should the nurse include in the plan?
Monitor the client's cardiac rhythm during thee procedure. The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an ECG.
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take?
Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.
What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? A. Perceptual disorders B. Impending coma C. Recent alcohol intake D. Depression with mutism
Option A: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal
What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse? A. Flat affect B. Expressing guilt C. Acting overly solicitous toward the child D. Ignoring the child
Option C: Acting overly solicitous (overly concerned, mindful, anxiously concerned) toward the child This behavior is an example of reaction formation, a coping mechanism.
In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcholine (Anectine) will be administered for which therapeutic effect? A. Short acting anesthesia B. Decreased oral and respiratory secretions C. Skeletal muscle paralysis D. Analgesia
Option C: Succinylcholine (Anectine)is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation
June has agreed to take amitriptyline HCL (Elavil) for 3 days, but now complains that it "doesn't help" and refuses to take it. What should the nurse say or do? A. Withhold the drug B. Record the client's response C. Encourage client to tell the physician D. Suggest that it takes awhile before seeing the results.
Option D: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the therapeutic blood level is reached.
Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is: A. Serve the client a bowl of soup B. Increase calories, decrease fat, and decrease carbohydrates C. Give the client pieces of cut up steak, potatoes, peas D. Increase calories, increase carbohydrates, and increase protein
Option D: This client needs increased protein for tissue building and increased calories to replace what is burned up (usually via carbohydrates); preferable, portable d/t acute mania sx Potatoes- does not indicate if portable
A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?
Phenylephrine. Clients on MAOIs should not take over-the-counter meeds for sinus congestion, colds, or allergies d/t the risk of severe hypertension.
A client has schizophrenia and reports auditory hallucinations. What interventions should be included in their care plan?
Promote the use of music to compete with the client's auditory hallucinations. This can assist in limiting the effect the hallucinations have on the client's stress level.
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?
Refrains from manipulating others to earn dining room privileges. The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior.
What is thee purpose of respite care?
Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?
Set realistic limits on the client's behavior. Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish limits on specific aggressive and demanding behaviors
A patient with schizophrenia is taking a conventional antipsychotic. Which of the following indicates the nurse should administer benztropine 2 mg IM?
Shuffling gait. Benztropine is used to treat parkinsonian manifestations.
Risk factors for depression
Single Presence of a negative life event Clients who have a chronic medical illness Female
What herb interacts adversely with paroxetine?
St. John's wort decreases reuptake of serotonin. Taking this herb with another med that inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome
Which of the following behaviors is consistent with dependent personality disorder?
The client needs excessive external input to make everyday decisions. Clients who have dependent personality disorder need excessive input from others to make everyday decisions.
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?
The client reports an inability to breath easily. Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?
The client will refrain from self-mutilation. The greatest risk to the client is injury to self and others.
Intervention for a client on clozapine that reports sore throat and chills?
This could indicate agranulocytosis. The nurse should withhold the med and notify the HCP.
