Psych Quiz 2 ATI Study Guide

A nurse is caring for a client who is actively dying. The clients partner is crying and holding the clients hand which of the following responses should the nurse make

I know this is difficult. Would you like me to sit with you?

The unit manager is evaluating the nurses understanding of occupational stress. Which of the following statements are examples the effects of occupational stress?

"Everyone is sick sometimes, but lately, with all the client deaths, the number of people calling in sick is increasing" "we had three more nurses hurt themselves during work last month" "sometimes, I have to work on other units where everyone feels negative. It is rough being on a different unit," "We have had so many of our longtime clients die these last few weeks. It's so overwhelming."

A nurse in a high school is caring for an adolescent who has recently suffered a traumatic loss of a classmate and is crying. Which of the following actions should the nurse take first?

Create a safe, nonjudgmental environment

A nurse manager is discussing sexual assault nurse examiners (SANEs) and the interventions they use when caring for clients who have been sexually assaulted. Which of the following interventions should the nurse include? A. A SANE informs the client of the requirement to file a police report B. A SANE instructs the client to follow-up with their provider in 2 months C. A SANE requests the police collect the physical evidence from the client's body following the assault. D. A SAME offers client

D. A SAME offers client some options about their care

A nurse is preparing to provide education to a client who is experiencing grief, which of the following information should the nurse include

Feelings of sadness can fluctuate in intensity when a person is grieving

A client who is experiencing prolonged grief (PGD) is at risk for which of the following?

Suicide, social dysfunction

A nurse is caring for a client in a clinic. The client states, "I am overwhelmed by stress." Which of the following should the nurse identify as the highest priority question to ask the client? "Do you have any relatives who have problems with stress?" "How much physical activity do you typically get in a day?" "What kinds of things do you find helpful for coping with your stress?" "How much sleep do you get each night?"

"What kinds of things do you find helpful for coping with your stress?" The highest priority during an initial assessment would be to determine what the client is doing to cope with stress at present, preferably via an open-ended inquiry.

Which of the following has been identified as a priority outcome of ensuring a nurse's physical and mental well-being?

A growing and sustainable future nursing workforce

A nurse is caring for a client who recently lost their partner in a motor vehicle crash. Which of the following actions should the nurse take to provide supportive grief informed care?

Ask the client how they met their partner

A nurse manager observes, a nurse, crying in the nurses locker room. Which of the following actions should the manager take first?

Use therapeutic communication to determine why the nurses crying

A nurse manager is assessing their unit for factors that contribute to the development of compassion fatigue which of the following factors should the nurse manager identify as increasing the risk for compassion fatigue?

A large number of nurses are working extra shift hours

A nurse is reviewing community assessments with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of community assessments? Select all that apply A. Community assessments are used to assess the needs of a particular community or population B. Community assessments identify conditions and disorders that are prevalent within a community C. Community assessments highlight areas of strength within a community or population D. Community assessments are the same as cultural assessments E. Community assessments are used to consider the services that are being used in the community

A, B, C, E

A nurse working at a community outreach center is speaking with a resident who reports, "I'm not sure where my child has gone. The come by daily to bring me meals and help me with my medications. It's been over 2 weeks and I can't reach them." The nurse should identify that the client is experiencing which of the following types of abuse? A. Abandonment B. Exploitations C. Physical D. Emotional

A. Abandonment

A nurse is caring for a client who is becoming aggressive. Which of the following de-escalation techniques should the nurse use? (Select all that apply) A. Approach the client with respect B. Respond to the clients concerns C. Block the doorway of the unit D. Address the client in a soft voice E. Stand in front of the client when talking

A. Approach the client with respect B. Respond to the clients concerns D. Address the client in a soft voice

A nurse is using the Clinical Judgement Action Model (CJAM) to guide a client's care. Which of the following tasks is designed to facilitate the analysis of cues? Select all that apply. A. Recognizing patterns B. Determining the order of priorities C. Linking cues D. Determining what is concerning E. Determining the need for additional information F. Collaborating with members of the interprofessional team

A. Recognizing patterns C. Linking cues D. Determining what is concerning E. Determining the need for additional information

A nurse is reviewing manifestations of non-suicidal self-harm (NSSH). Which of the following findings should the nurse identify as a warning sign that a client might be engaging in self-hard behavior? A. A client is talking to a friend about a recent job loss B. A client is wearing long-sleeve shirts in hot weather C. A client reports meditating when feeling upset D. A client who takes an aerobics class to decrease stress

B. A client is wearing long-sleeve shirts in hot weather

A nurse is discussing the role of a licensed practical nurse (LPN) with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the role of an LPN? A. An LPN can complete an independent assessment B. An LPN can report their observations to an RN C. An LPN can prioritize care based on the data that was collected D. An LPN can develop and provide client education

B. An LPN can report their observations to an RN

A nurse is caring for a client who was recently placed in seclusion due to their aggressive behavior. Which of the following statements made by the nurse indicates an understanding of the role the neurological system plays in relation to aggression? A. Excessive hypothalamus reaction and inadequate regulation of the prefrontal area will increase the likelihood on aggression in the client B. Excessive amygdala reaction and inadequate regulation of the prefrontal area will increase the likelihood

B. Excessive amygdala reaction and inadequate regulation of the prefrontal area will increase the likelihood on aggression in the client

A nurse on a behavioral health unit is caring for a newly admitted client who asks, "What is milieu therapy?" Which of the following responses should the nurse make? A. Milieu therapy is a type of therapy focused on assisting clients with identifying triggers of anxiety and fear B. Milieu therapy is focused on creating a safe environment for healing through trauma-informed therapeutic relationships C. Milieu therapy is a type of group therapy in which clients explore their thoughts, feelings, and experiences D. Milieu therapy is a type of individual therapy focused on connecting negative thoughts and behaviors

B. Milieu therapy is focused on creating a safe environment for healing through trauma-informed therapeutic relationships

A home health nurse is conducting an initial assessment on a client. Which of the following findings should indicate to the nurse that the client is potentially experiencing neglect? (Select all that apply) A. The client's daily medication are in a pill organizer. B. The client indicates their toilet has been non-functional for the last few weeks. C. The client's bed linens smell of urine D. The client's home has stacked boxes and clutter blocking the walkways E. The client's hair is dirty and

B. The client indicates their toilet has been non-functional for the last few weeks. C. The client's bed linens smell of urine D. The client's home has stacked boxes and clutter blocking the walkways E. The client's hair is dirty and tangled F. The client has a stage one pressure ulcer on their coccyx

A nurse is caring for a client who is at risk for isolation. Which of the following is the best outcome for this client? A. The client will remain in the community area at all times B. The client will attend 3 groups per day by the end of the week C. The client will attend family sessions. D. The client will eat meals with the other clients

B. The client will attend 3 groups per day by the end of the week

A nurse on a behavioral health unit is discussing the tasks of the Clinical Judgement Action Model (CJAM) with a group of newly licensed nurses. Which of the following information about analyzing cues should the nurse include? A. The nurse should identify subjective and objective data regarding the client's mental health condition B. The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration. C. The nurse should determine client mental health outcomes and appropriate nursing interventions. D. The nurse should monitor the client's responses to nursing interventions and changes in mental health status.

B. The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration.

A nurse enters the day room, observes the clients, and performs a situational assessment. Which of the following situations should the nurse identify as a priority to address. A. A client who is standing in front of a wall and staring blankly at it B. A client who does not want to go back to their room C. A client who is arguing with another client who is backed into a corner D. A client requesting to talk with a staff member in private

C. A client who is arguing with another client who is backed into a corner

A nurse is preparing to care for a client who is newly admitted. Which of the following actions should the nurse take immediately? A. Provide the client with an orientation to the unit rules B. Discuss the provider's prescriptions with the client C. Address the client's aggressive behavior towards staff D. Teach the client the purpose of their psychotherapy sessions

C. Address the client's aggressive behavior towards staff

A nurse is caring for a client who is speaking loudly and threatening to harm staff and other clients. Which of the following medications should the nurse anticipate the provider prescribing for this client? A. Fluoxetine B. Sertraline C. Chlorpromazine D. Duloxetine

C. Chlorpromazine

A nurse is caring for a client who reports that their partner threatens them when they disagree about finances. The nurse should identify that the client is experiencing which of the following types of abuse? A. Economic B. Physical C. Emotional D. Sexual

C. Emotional

A nurse is assessing a client who experienced abuse. Which of the following findings should the nurse expect? A. Trusting B. Independence C. Fear D. Confidence

C. Fear

A nurse is discussing the purpose of mental status assessments with a newly hired nurse. Which of the following information should the nurse include? A. Mental status assessments assess the client's family roles and functioning. B. Mental status assessments assess the client's coping abilities and strategies C. Mental status assessments assess a client's cognitive and behavioral functioning D. Mental status assessments assess the clients mental health and physical history

C. Mental status assessments assess a client's cognitive and behavioral functioning

A nurse is discussing individual and environmental factors of stress response with a group of newly licensed nurses. The nurse should include which of the following as individual factors? (Select all that apply.) a. Perception b. Temperament c. Lifestyle d. Culture e. Religion

Perception is correct. Perception is an individual factor that determines how a client may react to stress. Temperament is correct. Temperament is an individual factor that determines how a client may react to stress. Lifestyle is correct. Lifestyle is an individual factor that determines how a client may react to stress. Culture is incorrect. Culture is considered an environmental factor, not an individual factor. Religion is incorrect. Religion is considered an environmental factor, not an individual factor.

A nurse is caring for a client who has a history of anxiety and hypertension. The nurse should recommend which of the following relaxation techniques for the client? a. Biofeedback b. Prayer c. Reading a book d. Drawing

a. Biofeedback This relaxation method teaches the client physical and mental exercises to help control their specific automatic physical body functions, such as heart rate, blood pressure, and temperature.

A nurse is caring for a client who is exhibiting hypervigilance and restlessness. The client states, "I need to figure a way out of this mess." The nurse should recognize that the client is most likely in which of the following stages of anxiety? a. Mild b. Moderate c. Severe d. Panic

a. Mild The client is experiencing a mild level of anxiety. A mild level of anxiety can manifest in hypervigilance and restlessness. At this stage, the client may be open to problem solving and is likely at a peak level of concentration. Moderate A client experiencing a moderate level of anxiety may have increased vital signs and a diminished level of concentration. Severe A client experiencing a severe level of anxiety may report somatic symptoms and be unwilling to problem solve. Panic A client experiencing a panic level of anxiety may be unaware of their surroundings or display fight, flight, faint, freeze, or fawn behaviors.

A nurse is leading a group of clients in an outpatient setting. The nurse should recognize which of the following client statements as an example of a maladaptive defense mechanism? a. "When I get overly stressed at work, I need to just get out of there and go for a walk at lunch." b. "When my partner yells at the dog I run and hide, but I don't know why I do that." c. "When I am overly stressed, I will just sit and watch a movie to help me relax." d. "Losing my child to cancer is so painful that I decided to raise money for cancer research so nobody else has to go through this."

b. "When my partner yells at the dog I run and hide, but I don't know why I do that." This is an example of repression, which is a maladaptive defense mechanism. In repression, a client can admit that they have certain feelings or reactions about a stressor, but they will avoid thinking or talking about what led up to those feelings.

A nurse is preparing education for community support group about complicated grief, and resilience. Which of the following factors should the nurse identify as reducing a clients risk for developing complicated grief.

Regular religious or spiritual practice A sense of personal health and wellbeing A reliable support system

A nurse is providing teaching about stress with a client. The nurse should identify that which of the following client statements indicates an understanding of the teaching? a. "My stressor will all go away when I retire." b. "My stress could be related to my culture." c. "My attitude about my stressor can influence my coping." d. "I can decrease my stress by getting a new job."

c. My attitude about my stressor can influence my coping." A client's perception of themselves and their capability of managing stressors determines how they express their psychological and emotional response to stress.

A nurse is providing discharge instructions to a caregiver of a client who is dying. Drag words from the choices below to fill in each blank of the following sentence.

The nurse should recognize that the caregiver is experiencing (burnout) and (compassion fatigue)

A nurse is caring for a client who is dying. The clients family is at the bedside and have placed pictures and objects on the bed with the client. Which of the following actions should the nurse take?

Ask the family about the objects and their meaning

A nurse is discussing euthanasia with a coworker. Which of the following statements indicates an understanding of the role of nurses and euthanasia.

Euthanasia is illegal in the United States and the core values of nursing do not support it.

A nurse is caring for a client who has been newly diagnosed with a terminal illness and is experiencing significant stress. The client states, "Do you think a prayer would help?" Which of the following statements should the nurse make? a. "It could be that prayer is your only hope." b. "We do not have evidence that prayer helps, but it wouldn't hurt." c. "I can help you feel calmer by teaching you meditation exercises." d. "You may find prayer gives comfort and lowers your stress."

d. "You may find prayer gives comfort and lowers your stress." Many clients find that spiritual measures, including prayer, are helpful in mediating stress. Studies have shown that spiritual practices can enhance the client's sense of well-being. When a client suggests a viable means of reducing stress, it should be supported by the nurse.

A nurse is providing care to a client who was recently involved in a motor-vehicle crash. The nurse should identify that the client is in the moderate stage of anxiety based on which of the following behaviors? a. Answering questions with the response, "I am glad to be alive." b. Becoming unconscious after seeing a video of the accident c. Jumping off the bed and running out the door d. Practicing deep breathing with the nurse

d. Practicing deep breathing with the nurse The ability to learn and practice coping skills is a sign of mild and moderate levels of anxiety. Answering questions with the response, "I am glad to be alive." Repeating phrases is a sign of severe level of anxiety. Becoming unconscious after seeing a video of the accident Dissociation, or fainting, is seen in the panic level of anxiety. Jumping off the bed and running out the door This type of behavior is seen in the panic level of anxiety.

A nurse is assisting a client to develop a plan to reduce caloric intake. Which of the following interventions should the nurse include in the plan as a measurable goal for this client? ·The client will lose 3 kg (6.6 lb) of total body weight over the next 30 days. ·The client will record consuming no more than 1,800 calories per day. ·The client will provide a list of foods that they like to consume. ·The client will avoid using fried foods when preparing meals.

√The client will record consuming no more than 1,800 calories per day. This is an example of a measurable goal. The nurse should plan to use objective measurements, like calories consumed per day, or use a tool to translate subjective experiences into something that is measurable.

A nurse is working to build rapport and trust with a new client. Which of the following actions by the nurse could serve as a barrier to building rapport? ·The nurse fulfills a promise made to the client and allows them to use a telephone. ·The nurse reinforces the importance of the client's medication regimen. ·The nurse asks the client to clarify their most recent statement. ·The nurse uses clinical terminology to help the client better understand their diagnosis.

√The nurse uses clinical terminology to help the client better understand their diagnosis. The client's education level might serve as a barrier for building rapport. Initially, the nurse should use simple vocabulary when building rapport with the client and avoid clinical terminology.

A nurse is seeking to improve outcomes in mental health care by integrating technology in a local clinic. Which of the following actions should the nurse take to incorporate technology as a part of secondary prevention interventions? ·Distribute an email discussing risk factors for anxiety to a local community organization. ·Utilize a video conferencing application to perform a suicide risk screening. ·Refer clients to a website that provides strategies for reducing manifestations of depression. ·Identify factors that contribute to disparities in mental health.

√Utilize a video conferencing application to perform a suicide risk screening. This action by the nurse represents a strategy for incorporating technology as a secondary prevention intervention.

A nurse is working in a mental health facility in an occupational role. Which of the following activities is a function of the occupational role of the nurse? ·Participating on a health advisory board ·Referring the client for chaplain services ·Reinforcing client education on risk factors ·Assisting in developing community health policies

√Reinforcing client education on risk factors The occupational role of a nurse includes education, group facilitation, and care management. Participating on a health advisory board The social role of a nurse includes participating on health advisory boards, policymaking, and community advocacy. Referring the client for chaplain services The therapeutic role of the nurse includes coordinating spiritual leaders, processing emotional turmoil, and reinforcing cognitive behavioral techniques. Assisting in developing community health policies The social role of a nurse includes policymaking and community advocacy.

A nurse is providing education about medical aid in dying with a group of newly hired nurses. Which of the following statements by the newly hired nurse, indicates an understanding of the education.

An adult person with proven mental capacity self ingests the prescribed medication to die

A nurse is preparing a presentation for newly hired nurses about the role that nursing self care has on the social determinants of health. Which of the following information should the nurse include in the presentation?

Nurses must lead and model well-being among themselves before they can truly partner with others

A nurse is caring for a client who is demonstrating aggressive behavior towards others and is not responding to verbal interventions. Which of the following medications should the nurse anticipate the provider prescribing? A. Ziprasidone B. Paroxetine C. Escitalopram D. Lithium

A. Ziprasidone

The nurse is caring for an adolescent client, whose parents died four years ago. The clients other parent states that the client has been coming home drunk, lost her driving license due to reckless driving, and has been skipping school. Which of the following actions is the nurses priority.

Assess the client for risk of suicide

The nurse is caring for a client who is grieving and states no matter what I do I just can't stop crying. It feels like I am in the grave which of the following actions should the nurse take first

Ask the client what they mean by, "I'm in the grave"

A charge nurse is reviewing medical records of a client. Select the three findings found in the medical record that require immediate follow up by the charge nurse.

Nurses comment regarding their faith Nurses reference to euthanasia Nurses reference to clients age

A nurse on a mental health unit is caring for a client. Complete the following sentence by using the list of options. The nurse should first address the client's ____ followed by the client's ____. A. auditory hallucinations; restlessness and pacing B. heart rate; refusal to take medication C. WBC count; intake

A. auditory hallucinations; restlessness and pacing

A nurse is discussing the continuum of care with a client. Which of the following information should the nurse include? A. The continuum of care includes different clinical settings such as clinics and hospitals. B. The continuum of care is the basis for understanding levels and severity of mental illness C. The continuum of care occurs only during hospitalization D. The continuum of care increases the client's risk for urgent care visits

A. The continuum of care includes different clinical settings such as clinics and hospitals.

A nurse is screening a client for alcohol and tobacco use. Which of the following types of prevention is the nurse demonstrating? A. Primary B. Secondary C. Tertiary D. Selective

B. Secondary

A nurse is participating in a wellness check for an eight-year-old who was recently in a motor vehicle crash where both guardians were killed which of the following findings should the nurse identify as an indication that the child is experiencing traumatic guilt?

The child reports frequent stomach aches

The nurse is conducting a follow up visit with a client who is child was recently killed in a school shooting. The client states I don't know how to act or what to say. My child was the shooter. The nurse should determine that the client statement is consistent with which the following?

Disenfranchised grief

A nurse is caring for a client who has a care plan goal of having fewer than five panic attacks per week. The cleint is struggling to meet this goal. Which of the following actions should the nurse take? A. Work with the client to adjust the goal B. Encourage the client to better manage their panic attacks C. Remove the goal from the plan of care D. Change the interventions to eliminate PRN medication

A. Work with the client to adjust the goal

A nurse on an inpatient mental health unit is caring for a client. Select the three findings that require immediate intervention. A. Aggressive behavior B. Heart rate C. Respiratory rate D. Blood pressure E. Urine output

A. Aggressive behavior B. Heart rate D. Blood pressure

A charge nurse manager is reinforcing teaching to a newly licensed nurse about ways to provide culturally competent care. Which of the following instructions should the charge nurse provide? ·Encourage clients to adjust to the culture of the nurse caring for them. ·Exclusively participate in events focused on a single culture. ·Focus on working with clients from a familiar cultural background. ·Seek assistance from an interpreter for language barriers.

√Seek assistance from an interpreter for language barriers. The charge nurse should reinforce to the newly licensed nurse not to hesitate to contact an interpreter if they detect a language barrier or if the client does not respond to nonverbal cues of communication.

A nurse is reflecting on their performance after engaging with a client in an interview. Which of the following actions should the nurse plan to implement to improve receptiveness in their next client interview? ·Keep eye contact to a minimum. ·Sit at a slight angle across from the client. ·Cross legs to portray relaxation. ·Lean away from the client to build trust.

√Sit at a slight angle across from the client. If a client is feeling vulnerable, sitting directly in front of them might be perceived as confrontational. The nurse should sit across from the client at a slight angle to create a comfortable environment.

A nurse is caring for a client who is experiencing diaphoresis, palpitations, and a sense of impending doom. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepine b. Dopamine antagonist c. Selective serotonin reuptake inhibitor d. Mood stabilizer

a. Benzodiazepine

A nurse is participating in an interdisciplinary team meeting for clients on the unit. Which of the following actions should the nurse recommend to improve equity among the clients? ·Suggest complementary and alternative treatments for clients. ·Provide free or low-cost treatment options for all clients. ·Integrate each client's family in team meetings. ·Automatically refer each client to a local health care provider.

√Provide free or low-cost treatment options for all clients. Recommending this action will support equity among the clients. Equity ensures that each client has equal opportunity to initiate and continue fair treatment. Suggest complementary and alternative treatments for clients. Recommending this action will support diversity for clients. Diversity refers to the qualities of a client that differ from those of the nurse. Integrate each client's family in team meetings. Recommending this action will support inclusion. Inclusion refers to the ability of all care team members, including the client and those involved in their care, to voice their concerns with treatment and influence the decision-making process. Automatically refer each client to a local health care provider. Recommending this action will not support diversity, equity, or inclusion. The client's preference for treatment should be considered.

A nurse is seeking to improve outcomes in mental health care by integrating technology in a local clinic. Which of the following actions should the nurse take to incorporate technology as a part of tertiary prevention interventions? ·Organize a video streaming event to raise awareness about mental illness. ·Utilize an electronic survey to help identify at-risk clients. ·Refer clients to a support group that meets on social media. ·Host peer-facilitated support groups for clients who struggle with addiction.

√Refer clients to a support group that meets on social media. This action by the nurse represents a strategy for incorporating technology as a tertiary prevention intervention.

A nurse is using considerations from Leininger's Transcultural Nursing Theory to plan care for a client who is from a different culture than the nurse. Which of the following actions should the nurse plan to take to demonstrate the consideration of cultural preservation? ·Request specific meal tray items to support a client's spiritual beliefs. ·Provide education about the client's illness. ·Assist the client with planning for diet alternatives. ·Administer medications in replacement of herbal remedies.

√Request specific meal tray items to support a client's spiritual beliefs. The nurse demonstrates cultural preservation by seeking to retain the client's core cultural beliefs and values related to healthcare, such as diet and clothing preference.

A nurse is helping a client develop a plan for successful behavior change. Which of the following interventions should the nurse include in the plan? ·Allow the client to choose a range of guidelines for success. ·Implement the use of a reflective journal to measure success. ·Provide a general list of resources that are popular for most clients. ·Schedule an appointment with a provider who lives within walking distance of the client.

√Schedule an appointment with a provider who lives within walking distance of the client. The nurse should plan to work within the constraints of available resources for the client.

A nurse is caring for a client who experiences aggression. Which of the following statements made by the client indicates the client experiences hostile aggression? A. I let off steam by yelling out loud B. I shattered a plate because I stubbed my toe in the kitchen C. They made me mad so I hit them D. I clinch my fist when I have to wait in traffic

C. They made me mad so I hit them

A nurse is preparing to begin caring for a client in discovers that the client adult children were recently killed as a result of gun violence. Which of the following actions should the nurse take?

Spend time reflecting and planning to avoid imposing any personal bias

A nurse is caring for a client undergoing a procedure and encourages the client to imagine themselves lying on the beach. Which of the following coping styles is the nurse suggesting? Guided imagery Deep breathing Fantasy Adjusting expectations

Guided imagery The nurse is suggesting guided imagery. In guided imagery, the client imagines being in a place that represents calmness and relaxation.

A nurse is presenting an in-service on the cycle of violence to a nursing staff. The nurse should include that the perpetrator becomes affectionate at which of the following phases? A. Acute battering B. Build-up C. Displacement D. Respite

D. Respite

A nurse is teaching about the purpose of participating in a therapy group about coping strategies. Which of the following client statements indicates an understanding of the teaching?

Learning positive coping strategies can help me adapt to life after the death of my partner

A nurse in the ED is caring for a client who has acute haloperidol toxicity. Which if the following findings should the nurse identify as consistent with neuroleptic malignant syndrome? a. Dilated pupils and GI discomfort b. Hyperthermia and elevated creatinine kinase c. Respiratory depression and comatose state d. Slumped posture and shuffling gait

b. Hyperthermia and elevated creatinine kinase

A nurse is caring for a client who is experiencing opiate toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepines b. Diphenhydramine c. Naloxone d. Methadone

c. Naloxone

A nurse is performing a mental status examination for a newly admitted client. Which of the following questions should the nurse include in the examination? A. How would you describe your mood today? B. What is the date today? C. What is your pain level on a scale of 0 to 10? D. Can you please show me how to use this pen? E. Why are you wearing a coat when it is hot today?

A. How would you describe your mood today? B. What is the date today? D. Can you please show me how to use this pen?

A nurse is providing care to a client who has a history of violent behavior. The nurse should identify which of the following client statements as a risk factor for potential (future) violent behavior? (Select all that apply) A. I don't really have a lot to be proud of B. When I get mad, I make myself count to 10 and take deep breaths C. I drink a half gallon of vodka everyday D. I occasionally use cocaine E. I have been arrested two times for a domestic disturbance F. Sometimes I yell at peopl

A. I don't really have a lot to be proud of C. I drink a half gallon of vodka everyday D. I occasionally use cocaine E. I have been arrested two times for a domestic disturbance F. Sometimes I yell at people who cut me off when I'm driving

A nurse is caring for a client who is experiencing extreme anger. Which of the following client statements should the nurse identify as being consistent with adverse childhood experiences (ACEs)? (Select all that apply) A. My parents separated when I was 9 years old B. My siblings and I would stay alone for days at a time while my parents was gone C. My older sibling dies of a heroine toxicity when I was 12 years old D. My parent remarried and just celebrated their fifth wedding anniversary E.

A. My parents separated when I was 9 years old B. My siblings and I would stay alone for days at a time while my parents was gone C. My older sibling dies of a heroine toxicity when I was 12 years old E. My parents used to hit my siblings and I with a belt when we were younger F. When I was younger, I experiences drive-by shootings in my neighborhood

A nurse is providing care to a client who has a history of anger. The nurse should identify that the comorbidities of anger include which of the following disorders? (Select all that apply) A. Binge-eating disorder B. PTSD C. Substance abuse disorder D. Conduct disorder E. Attention deficit disorder F. OCD

B. PTSD C. Substance abuse disorder D. Conduct disorder E. Attention deficit disorder

A nurse is caring for a client who has been physically abusive to others and was admitted to an inpatient mental health unit. Which of the following client behaviors should the nurse identify as early signs of potential aggression? (Select all that apply) A. Socializing with selected individuals B. Refusing to eat C. Speaking in a soft voice D. Pacing the floor E. Destroying items F. Attempting to leave before discharge

B. Refusing to eat D. Pacing the floor E. Destroying items F. Attempting to leave before discharge

A nurse is providing teaching to a newly licensed nurse who is caring for a client experiencing aggression related to PTSD. Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching? A. The client has an increase in dopamine which results in aggressive behavior B. The client has an excess of serotonin which results in aggressive behavior C. The client has a decrease in histamine which results in aggressive behavior D. The client has an increas

B. The client has an excess of serotonin which results in aggressive behavior

A nurse is reviewing the purpose of the DSM-5 with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. The DSM-5 is a resource that outlines nursing interventions for clients who have been diagnosed with a mental health disorder. B. The DSM-5 is a resource that provides health care professionals with information on the best course of treatment for mental health disorders C. The DSM-5 is a resource that provides information about the clinical manifestations of specific mental health disorders D. The DSM-5 is a resource that outlines discharge planning and continuity of care across cleint populations

C. The DSM-5 is a resource that provides information about the clinical manifestations of specific mental health disorders

A nurse is discussing non-suicidal self-hard (NSSH) with a newly licensed nurse. Which of the following statements should the nurse make? A. NSSH is considered attention-seeking behavior B. NSSH is most often initiated as an adult C. There are no serious physical health effects from NSSH D. Clients who engage in NSSH rarely seek medical attention

D. Clients who engage in NSSH rarely seek medical attention

A nurse is caring for a client who was administered antianxiety medication 1 hr ago. Which of the following statements by the nurse indicates that the nurse is using the evaluation step of the nursing process? A. How does your anxiety affect your ability to work? B. Have you had anxiety in the past? C. What is the dosage of the antianxiety medication that you take at home? D. How is your anxiety level now?

D. How is your anxiety level now?

A nurse is explaining the purpose of the Family Assessment Device (FAD) to the parents of a child. Which of the following statements by a parent indicates an understanding of the FAD? A. The FAD is used to help assess family functioning, specifically the impact of trauma and crisis on family functioning B. The FAD is used to help assess family functioning, specifically in the areas of housing and financial security C. The FAD is used to help assess family functioning, specifically to determine the need to notify Child Protective Services of any family problems D. The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics

D. The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics

A nurse is assisting in the care of a client who states, "When I am stressed at work, I can't help coming home and arguing with my partner." The nurse should recognize that the client is exhibiting which of the following defense mechanisms? Intellectualization Projection Sublimation Displacement

Displacement This client is exhibiting displacement, which is a maladaptive defense mechanism. In displacement, an individual redirects their stress to someone they feel safe with instead of directing it toward the cause of the stressor.

The nurse is caring for a client who has sustained life-threatening injuries. The healthcare team is discussing withdrawal of life-sustaining treatment. The decision to withdraw treatment is made by which of the following?

The health care team and the family

A nurse is educating a newly licensed nurse about the purpose of neurotransmitters. Which of the following statements by the newly licensed nurse indicates understanding of the education? a. "Dopamine is responsible for inhibiting behaviors caused by stress." b. "Serotonin is responsible for regulating sleep and body temperature." c. "Norepinephrine is primarily responsible for symptom presentations related to schizophrenia." d. Histamine is an excitatory neurotransmitter that is responsible for pain management and pleasure."

b. "Serotonin is responsible for regulating sleep and body temperature."

A nurse is participating in an interdisciplinary team meeting for clients on the unit. Which of the following actions should the nurse recommend to improve diversity among the treatment team? ·Integrate clinicians from various cultural backgrounds into the team meeting. ·Include nonlicensed staff members in the team meeting. ·Include each client in team meetings. ·Initiate autocratic leadership into meetings.

√Integrate clinicians from various cultural backgrounds into the team meeting. To support diversity among the interdisciplinary team, the nurse should recommend integrating clinicians from various cultural backgrounds.

A nurse is preparing to discharge a client. Which of the following actions should the nurse plan to take to improve the client's level of functioning beyond the nurse-client relationship? ·Establish boundaries. ·Recognize educational needs. ·Affirm client attitude toward treatment. ·Provide community resource referrals.

√Provide community resource referrals. The nurse should provide community referrals and resources in the resolution phase of the nurse-client relationship.

A nurse is caring for a client who states, "I don't think medications are for me." Which of the following statements should the nurse make? ·"You should trust that your provider knows what's best for you." ·"I think medications are your best option." ·"Tell me more about what you feel would work best for you." ·"Alternative forms of treatment seldom work."

√"Tell me more about what you feel would work best for you." This statement by the nurse is an open-ended therapeutic statement that invites the client to share their ideas or emotions.

A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following should the nurse include in the interview to encourage the client to continue sharing feelings and information? ·"Do you understand your next step for discharge?" ·"What are some of the stressors that you have in your life?" ·"Would you like more information on social support?" ·"You understand your medications and are ready to discharge."

√"What are some of the stressors that you have in your life?" Open-ended questions allow the client to elaborate on what is important to them in their own words. It is an open invitation to share feelings and information.

A nurse is facilitating a group session on adaptive defense mechanisms. The nurse should identify which of the following client statements as examples of adaptive defense mechanisms? (Select all that apply.) a. "When I get stressed out, I like to go to the gym." b. "I volunteer at a local substance use help group." c. "When I get home from school, it's hard to hear things for hours after." d. "When people are mean to me, I am mean right back to them." e. "I was so upset after I failed my exam that I broke my laptop."

"When I get stressed out, I like to go to the gym" is correct. This is an example of sublimation, which is an adaptive defense mechanism. Sublimation occurs when an individual puts their energy into something constructive to change stressful feelings or emotions. "I volunteer at a local substance use help group" is correct. Volunteering at a substance abuse help group is an example of an adaptive defense mechanism. This would be altruism, which is when an individual transforms their feelings and emotions by helping others who are experiencing something similar. "When I get home from school, it's hard to hear things for hours after" is incorrect. This is an example of conversion, a maladaptive defense mechanism. Conversion occurs when an individual experiences a loss of sensory functioning. "When people are mean to me, I am mean right back to them" is incorrect. This is a maladaptive example of a identification. Identification occurs when an individual is assuming the characteristics of the individual who is expressing negative feelings towards them. "I was so upset after I failed my exam that I broke my laptop" is incorrect. This is an example of a maladaptive use of regression. Regression is when an individual returns to a previous developmental stage of behavioral, cognitive, or emotional functioning.

A nurse on an inpatient mental health unit is using the Clinical Judgement Action Model (CJAM) to guide their care of a client. Which of the following tasks should the nurse complete to generate solutions? Select all that apply A. Determine desired outcomes B. Determine the best solution based on evidence C. Determine what resources are needed, including people, equipment, and medications D. Determine cues that need to be analyzed E. Prioritize client care

A. Determine desired outcomes B. Determine the best solution based on evidence C. Determine what resources are needed, including people, equipment, and medications

A nurse on a mental health unit is reviewing a clients medical record. Click to identify if each action is performed during the assessment of intervention phase of the nursing process. A. Determine if the client has a history of violence B. Communicate with the client using simple terms C. Administer an anxiolytic medication D. Place the client in a low-stimulation environment E. Check the client for delusional thoughts

A. Determine if the client has a history of violence - Assessment B. Communicate with the client using simple terms - Intervention C. Administer an anxiolytic medication - Intervention D. Place the client in a low-stimulation environment - Intervention E. Check the client for delusional thoughts - Assessment

A charge nurse is preparing an in-service for staff members about non-suicidal self-harm (NSSH). Which of the following information should the nurse include? A. NSSH is often used as a way to release painful emotions B. NSSH indicates a client has developed a plan for suicide C. NSSH occurs more often in males than females D. NSSH is generally not dangerous to a clients physical health

A. NSSH is often used as a way to release painful emotions

A group of nurses is discussing implementation of a plan of care for a client who has a mental illness. Which of the following nursing actions should be included when implementing a plan of care? Select all that apply. A. Prioritize establishing a therapeutic relationship B. Focus on client-centered, holistic care rather than the client's diagnoses C. Limit family involvement when executing the plan of care D. Gather data related to the client's clinical manifestations E. Accurately document implementation of the plan of care

A. Prioritize establishing a therapeutic relationship B. Focus on client-centered, holistic care rather than the client's diagnoses E. Accurately document implementation of the plan of care

A nurse is caring for a client. Which of the following actions by the nurse demonstrates the evaluating outcomes step of the Clinical Judgement Action Model (CJAM)? A. Revising the plan of care B. Handling psychiatric emergencies C. Providing evidence for hypothesis D. Determining if additional information is needed.

A. Revising the plan of care

A group of nurses is discussing the effectiveness of nursing interventions among clients who have a mental health diagnosis. Which of the following statements accurately identifies a barrier to effective nursing interventions? Select all that apply A. Some mental health clients are unaware that they have a mental health condition B. Some mental health clients experience cognitive deficits and cannoy understand their treatment plan C. Many mental health clients experience the effects of polypharmacy D. Many mental health clients are not trustworthy E. Many mental health clients experience worsening clinical manifestations

A. Some mental health clients are unaware that they have a mental health condition B. Some mental health clients experience cognitive deficits and cannoy understand their treatment plan C. Many mental health clients experience the effects of polypharmacy E. Many mental health clients experience worsening clinical manifestations

A nurse is evaluating a client whose partner is concerned about their episodes of recurrent anger. Which of the following statements should the nurse make when explaining potential reasons for the client's anger? (Select all that apply) A. The client gets a rush of adrenaline when expressing anger B. The client wants to harm someone they think harmed them C. The feeling of anger and aggression helps the client to problem solve D. The client thinks their anger is justified E. The client feels po

A. The client gets a rush of adrenaline when expressing anger B. The client wants to harm someone they think harmed them D. The client thinks their anger is justified E. The client feels powerful when angry F. When the client is angry, their self-esteem is boosted.

A nurse in the emergency department is caring for a client who states they fell down the stairs this morning. Which of the following assessment findings indicates the client might be experiencing physical abuse? (Select all that apply) A. The client has bruises in various stages of healing on their back B. The clients eyeglasses are cracked C. The client is visible uneasy when their partner enters the area D. The client has a scar on their upper arm E. The client has ligature marks around both

A. The client has bruises in various stages of healing on their back B. The clients eyeglasses are cracked C. The client is visible uneasy when their partner enters the area E. The client has ligature marks around both wrist F. The client has an open, discolored wound on their shoulder

A nurse is teaching a newly licensed nurse who is caring for a client who has previously demonstrated aggressive and violent behavior. Which of the following statements should the nurse make? (Select all that apply) A. The clients aggression might be linked to their history of schizophrenia B. A client who has heart failure tends to be aggressive C. A client who has a traumatic brain injury may demonstrate violent behaviors D. A client who has bipolar I disorder could be at a higher risk for da

A. The clients aggression might be linked to their history of schizophrenia C. A client who has a traumatic brain injury may demonstrate violent behaviors D. A client who has bipolar I disorder could be at a higher risk for danger to others E. A client who has been sexually abused might experience aggressive episodes F. A child who has autism might experience episodes of aggression

A nurse is discussing risk factors of negative stress responses with a group of clients. The nurse should include which of the following risk factors in the discussion? (Select all that apply.) Birth order Temperament Interpersonal violence Health behaviors Financial stability Sex

Birth order is incorrect. Birth order has not been identified as increasing the risk for experiencing stress. Temperament is correct. A client's temperament can affect how they experience and handle stress. Interpersonal violence is correct. Social risk factors, such as interpersonal violence, can predispose clients to an increased stress response. Health behaviors is correct. A client's health and health behaviors can affect how they experience and handle stress. Financial stability is incorrect. Financial insecurity can impact how clients experience and handle stress, but it is not identified as a risk factor. Sex is incorrect. Biological and genetic makeup of the client—including underlying health conditions, sex, and age—are factors that influence the stress response, but they are not risk factors.

A nurse is caring for a client who is exhibiting manifestations of anxiety. Which of the following manifestations would the nurse expect to see increase during the client's flight or flight response? (Select all that apply.) a. Blood pressure b. Heart rate c. Respiratory rate d. Bowel sounds e. Pupillary response

Blood pressure is correct. Blood pressure, heart rate, respiratory rate, and pupillary response are all affected by the body's physiological responses to stress. Heart rate is correct. Blood pressure, heart rate, respiratory rate, and pupillary response are all affected by the body's physiological responses to stress. Respiratory rate is correct. Blood pressure, heart rate, respiratory rate, and pupillary response are all affected by the body's physiological responses to stress. Bowel sounds is incorrect. Bowel sounds would decrease in a flight or flight response. Respiratory rate is correct. Blood pressure, heart rate, respiratory rate, and pupillary response are all affected by the body's physiological responses to stress.

A charge nurse is providing an in-service to a group of staff nurses about the role of a forensic nurse. Which of the following information should the nurse include? A. Counsel the client about the incident B. Request the police gather evidence of the incident C. Encourage the client to seek legal charges against the perpetrator D. Provide legal testimony as requested by the client

D. Provide legal testimony as requested by the client

A nurse is caring for a client and notes that the client has become increasingly restless over the last hour. This is an example of which of the following steps of the Clinical Judgement Action Model (CJAM)? A. Taking action B. Prioritizing hypothesis C. Analyzing cues D. Recognizing cues

D. Recognizing cues

A nurse is caring for a client who has emphysema and recently reduced their level of activity because they fear developing dyspnea. When teaching the client to use guided imagery, which of the following should the nurse encourage the client to visualize? Walking on a beach without using supplemental oxygen Sleeping comfortably and soundly, without respiratory distress Placing their hand to feel the rise and fall of their chest Dangling feet in a pool and taking regular deep breaths

Dangling feet in a pool and taking regular deep breaths. The client has a dysfunctional perspective of dyspnea. Guided imagery can help replace the dysfunctional image with a positive coping image. Encouraging the client to imagine a regular breathing pattern will help improve oxygen-carbon dioxide exchange and facilitate relaxation.

The nurse is caring for a client who was diagnosed with ALS, has been hospitalized for aspiration pneumonia, and has failed a swallowing evaluation. The provider determined the need for a feeding tube to be inserted. However, the client is refusing to have the tube inserted. The nurse is experiencing moral distress, which of the following actions should the nurse take first?

Identify the area of concern

A nurse is reinforcing teaching about physiological responses to stress with a group of clients. The nurse should include which of the following short-term physiological changes in the teaching? (Select all that apply.) a. Increase in muscular tension, blood pressure, and triglycerides b. Increase in heart rate and respiratory rate c. Corticosteroid release increases stamina and impedes digestion d. Cortisol release increases glucogenesis and reduces fluid loss e. Increased immune system function f. Increased risk of depression, autoimmune disorders, and heart disease

Increase in muscular tension, blood pressure, and triglycerides is correct. This is a short-term physiological response to stress. Increase in heart rate and respiratory rate is correct. This is a short-term physiological responses to stress. Corticosteroid release increases stamina and impedes digestion is correct. This is a short-term physiological response to stress. Cortisol release increases glucogenesis and reduces fluid loss is correct. This is a short-term physiological response to stress. Increased immune system function is incorrect. Stress would cause the immune system to decrease rather than increase. Increased risk of depression, autoimmune disorders, and heart disease is incorrect. Increased risk of cancer, cardiovascular disease, depression, and autoimmune disease are all long-term (chronic) effects of stress.

A nurse is caring for a client who is experiencing chronic stress. Which of the following does the nurse anticipate that the client will report? (Select all that apply.) Increased anxiety Recurring sinus infections Feelings of depression Sudden bursts of energy Daily overeating Heart palpitations

Increased anxiety is correct. With chronic stress, the body becomes overwhelmed resulting from the accumulation of the effects of the stressors over time. Some of the psychological and physiological effects of chronic stress include depression, anxiety, and recurring infections. Recurring sinus infections is correct. With chronic stress, the body becomes overwhelmed resulting from the accumulation of the effects of the stressors over time. Some of the psychological and physiological effects of chronic stress include depression, anxiety, and recurring infections. Feelings of depression is correct. With chronic stress, the body becomes overwhelmed resulting from the accumulation of the effects of the stressors over time. Some of the psychological and physiological effects of chronic stress include depression, anxiety, and recurring infections.

A nurse is caring for a client who has recently experienced the death of a partner. Based on the client findings which of the following three actions, should the nurse take?

Perform an ongoing assessment of the clients emotional status Encourage the client to talk about the death of their partner Encourage the client to discuss their daily routine

A nurse is assisting in the care of a client who states, "My cardiologist told me that I need to reduce stress. What is the best way for me to do that?" Which of the following responses should the nurse make first? "Physical exercise has been shown to be beneficial in reducing stress." "Self-help books are a good way to learn strategies to reduce stress." "It might be a good idea for you to try painting to help reduce your stress." "Tell me more about the stressors that you are facing in your life."

Tell me more about the stressors that you are facing in your life." Using the nursing process as a priority framework, assessment of the client comes first. By assessing the stressors that the client is facing, the nurse is able to discuss options that may be most beneficial to the client.

A nurse is caring for a client who reports having a headache, nausea, difficulty sleeping. The client states " my dog died a few weeks ago and I miss them so much". Which of the following statements by the nurse demonstrates a grief informed approach.

The loss of your dog must be difficult. Can you share what happened?

A nurse in a mental health clinic is caring for a client who is grieving the loss of a child. Complete the following sentence by using the list of options

The nurse should provide client education about (complicated grief therapy) that focuses on (strengthening relationships)

A nurse is caring for a client who was recently diagnosed with prolonged grief disorder(PGD) which of the following client statements should the nurse address?

There is nothing to do I just can't go on living without my child

A nurse is caring for a client who has end-stage pancreatic cancer. The client has decided to forgo any additional treatment and be allowed to die. Which of the following responses should the nurse make to honor the clients request?

This action is supported by your right of self-determination.

A nurse is educating a newly licensed nurse about manifestations of alcohol withdrawal. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "An increase in the release of the neurotransmitter glutamate causes an elevated heart rate." b. "A decrease in the release of the neurotransmitter dopamine causes a sense of euphoria." c. "An increase in the release of the neurotransmitter serotonin causes muscle aches." d. "A decrease in the release of the neurotransmitter norepinephrine causes nausea."

a. "An increase in the release of the neurotransmitter glutamate causes an elevated heart rate."

A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. When assessing the client, which of the following purposes describes the function of the CIWA-Ar scale? a. Determine the client's severity of alcohol withdrawal and adjust care accordingly b. Determine the client's risk of developing severe manifestations c. Identify genetic factors that influence alcohol withdrawal d. Analyze and interpret lab and medical imaging data

a. Determine the client's severity of alcohol withdrawal and adjust care accordingly

A nurse is caring for a client who has been taking risperidone and reports experiencing muscle spasms in their neck and difficulty opening their mouth. Which of the following medications should the nurse anticipate the provider to prescribe for this client? a. Diphenhydramine b. Valbenazine c. Escitalopram d. Naloxone

a. Diphenhydramine

A nurse is educating a newly licensed nurse about opiate withdrawal. Which of the following findings should the nurse instruct the newly licensed nurse to monitor for? a. Muscle aches b. Respiratory depression c. Hallucinations d. Increased risk of seizure

a. Muscle aches

A nurse is assisting in planning education for a group of teachers on personality traits. Which of the following traits describes a student who is eager to learn? a. Openness b. Extraversion c. Conscientiousness d. Agreeableness

a. Openness Openness describes an individual who is eager to learn and experience new things. Extraversion Extraversion describes an individual who is assertive and outgoing. Conscientiousness Conscientiousness describes an individual who is efficient and organized. Agreeableness describes an individual who is forgiving, warm, and not demanding.

A nurse is caring for a client who was in a motor-vehicle crash. The client states, "I had to get home before 6pm so I had to drive really fast." Which of the following defense mechanisms is the client exhibiting? a. Rationalization b. Displacement c. Identification d. Altruism

a. Rationalization This client is exhibiting rationalization. In rationalization, a person uses reason or logic to avoid or explain the stressor and avoid their emotions.

A nurse is preparing a presentation for high school students about the causes of mental illness. Which of the following should the nurse include in the presentation? a. Stress has been identified as a potential cause of mental illness b. Manifestations of mental illness can be resolved through motivation c. Medications serve as a cure for mental illness d. Psychotherapy can serve as a cure for mental illness

a. Stress has been identified as a potential cause of mental illness

A nurse is providing education to the partner of a client who exhibits poor muscle function, poor memory, and poor concentration. Which of the following statements should the nurse make when explaining the client's findings to the partner? a. "Glutamate interacts with GABA in the brain, causing an individual to experience manifestations of poor motor movements." b. "A dysfunction in acetylcholine receptors may be a cause for motor movement dysfunction." c. "Norepinephrine is a neurotransmitter that is primarily responsible for muscle movement." d. "Recreational drugs that block histamine receptors cause manifestations of psychosis."

b. "A dysfunction in acetylcholine receptors may be a cause for motor movement dysfunction."

A nurse is assisting in the care of a client who attempted to die by suicide. The client is currently undergoing cognitive behavioral therapy. Which of the following statements by the client indicates that the therapy has been effective? a. "I have removed all of the mirrors from my house." b. "I guess I am fortunate to have survived my suicide attempt." c. "It is hard to go out when you know that everyone is laughing at you." d. "At least now when people stare at me, I have enough courage to tell them off."

b. "I guess I am fortunate to have survived my suicide attempt." Cognitive behavioral therapy works to help the client adjust to or unlearn negative thoughts and change them to more positive thoughts, attitudes, or emotions. This statement by the client indicates that the therapy has been effective because the client has changed their negative thoughts to a positive thought.

A nurse is teaching a client about potential risks of chronic stress. Which of the following conditions should the nurse include as a potential risk? a. Peripheral vascular disease b. Diabetes c. Seizures d. Meningitis

b. Diabetes Chronic stress is known to increase the risk of many mental and physical conditions, including type 2 diabetes mellitus. PVD Chronic exposure to cortisol can increase an individual's risk for developing cardiovascular disease, obesity, anxiety, and insomnia, not peripheral vascular disease. Seizures Chronic exposure to cortisol can increase an individual's risk for developing cardiovascular disease, obesity, anxiety, and insomnia, not seizures. Meningitis Chronic exposure to cortisol can increase an individual's risk for developing cardiovascular disease, obesity, anxiety, and insomnia, not meningitis.

A nurse is reinforcing education to a client who is afraid of heights and is planning to drive across a high bridge. The nurse should identify that which of the following structures stimulates the automatic nervous system? a. Thalamus b. Hypothalamus c. Parietal lobe d. Pituitary gland

b. Hypothalamus The client will find that driving across a high bridge is stressful. The hypothalamus functions as the command-and-control center, responding to signals of stress by engaging the autonomic nervous system. Thalamus The thalamus processes messages associated with pain and wakefulness but will not stimulate the autonomic nervous system. Parietal lobe The parietal lobe is responsible for interpretation of other sensations but will not stimulate the autonomic nervous system. Pituitary Gland The pituitary gland may be involved in other aspects of the client's response but will not stimulate the autonomic nervous system.

A nurse us reviewing the serum lithium report for a client who has bipolar disorder. Which of the following manifestations should the nurse expect the client to be experiencing with a lithium level of 2.2 mEq/L? a. Severe respiratory complications b. Jerking motor movements c. GI discomfort d. Abnormal involuntary movements of the tongue

b. Jerking motor movements

A nurse is caring for a client who is prescribed a tricyclic antidepressant medication. Which of the following topics should the nurse prepare to discuss with the client? a. It is important to take the medication first thing in the morning b. Relief of manifestations should not be expected for a few weeks c. There are benefits associated with combining tricyclic antidepressant with St. John's Wort d. Foods that are known to be high in dietary tyramine should be avoided

b. Relief of manifestations should not be expected for a few weeks

A nurse is caring for a client who has mood dysregulation, decreased sex drive, and decreased sleep. Which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations? a. Dopamine b. Serotonin c. Norepinephrine d. Histamine

b. Serotonin

A nurse is caring for a client who is prescribed citalopram and is being monitored for activation syndrome. Which of the following findings should the nurse identify as an indicator of activation syndrome? a. High blood pressure b. Suicidal ideations c. Tremors and confusion d. Trouble sleeping and increased anxiety

b. Suicidal ideations

A nurse in a mental health clinic is observing a client in the day room. The nurse should identify which of the following actions by the client as a maladaptive defense mechanism? a. The client is sitting down and is painting a picture. b. he client tells another client that all of the therapists are mean. c. The client crumbles up their paper and throws it across the room. d. The client is talking about starting a fundraiser for other people who lost everything in a fire.

b. he client tells another client that all of the therapists are mean. This client is exhibiting splitting, which is a maladaptive defense mechanism. The maladaptive defense mechanism of splitting is when a person is unable to accept that an individual can have both good and poor aspects but believes someone is all "bad" or all "good."

A nurse is educating a group of high school students about mental illness. Which of the following statements should the nurse make about etiology of a mental illness? a. "Schizophrenia can be detected through a complete blood count." b. "It is possible to predict the likelihood of developing manifestations of a mental illness." c. "Developing a mental illness seems to be related to both genetic and environmental factors." d. "Regular physical examinations are commonly used to diagnose mental illness."

c. "Developing a mental illness seems to be related to both genetic and environmental factors."

A nurse is providing education to the family of a client who is experiencing psychosis. Which of the following statements should the nurse make when explaining the role of glutamate in this disorder? a. "Glutamate is an excitatory neurotransmitter that is responsible for learning and memory." b. "Glutamate is essential to sleep and muscle functioning." c. "Glutamate is responsible for affective and cognitive functioning." d. "Glutamate regulates the release of histamine and serotonin."

c. "Glutamate is responsible for affective and cognitive functioning."

A nurse is providing education to a client about the process of neurotransmission. Which of the following statements about neurotransmission should the nurse make? a. "Neurotransmitters function by storing glucose in vesicles found in neurons." b. "Neurotransmitters are rarely found in the brain." c. "Neurotransmitters are chemical components that allow neurons to communicate with each other." d. "After a neurotransmitter completes neurotransmission, it is then activated by the enzyme transferase."

c. "Neurotransmitters are chemical components that allow neurons to communicate with each other."

A nurse is assisting in the care of a client whose partner recently died. The client asks, "Do you think meditation helps with stress?" Which of the following responses should the nurse make? a. "I will give you some meditation techniques that I use to help with stress." b. "There is no clinical evidence that meditation helps, but it wouldn't hurt." c. "You may find meditation gives comfort and lowers your stress." d. "Using meditation along with another effective coping strategy may help you."

c. "You may find meditation gives comfort and lowers your stress." This response addresses the client's concerns and affirms the client's choice to try meditation as a form of stress management.

FLAG A nurse is leading a group of clients who are using the Holmes-Rahe Life Stress Inventory Scale to self-assess stressors in their life. Which of the following findings indicates the highest degree of stress? a. A client who has reported being assigned more responsibility at work b. A client with children who will be relocating to a new city for work. c. A client who is returning to college following the loss of their job d. A client who is recently separated from their spouse

c. A client who is returning to college following the loss of their job A client who is returning to college after losing a job is dealing with two significant stressors simultaneously.

A nurse is caring for a client who states, "I am so stressed over my upcoming reunion because I am not as successful as most of my classmates." Which of the following therapies for stress related disorders may benefit this client? a. Aversion therapy b. Biofeedback c. Cognitive reframing d. Desensitization therapy

c. Cognitive reframing This client would benefit from cognitive reframing, which is a technique used to change the way a person thinks about something. Aversion therapy Aversion therapy is used to treat clients with a substance use disorder. Biofeedback Biofeedback uses biosensors to monitor physiological responses to stressors in order to inform the client how their body responds to stress. Desensitization therapy Desensitization therapy is used to treat clients who have phobias.

A nurse is caring for a client who has a diagnosis of bipolar disorder and recently begun lithium therapy. Which of the following manifestations should the nurse identify as indicative of early lithium toxicity? a. Blurred vision and tinnitus b. Muscle jerking and stupor c. Nausea and coarse tremors d. Respiratory distress and a comatose state

c. Nausea and coarse tremors

A nurse is caring for a client who is experiencing disruptions in sleep, appetite, and reports having a depressed mood. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepine b. Dopamine antagonist c. Selective serotonin reuptake inhibitor d. Mood stabilizer

c. Selective serotonin reuptake inhibitor

A nurse is educating a client about mental illness treatment and the client asks, "Why do some medications that treat mental illness take a few weeks to be come effective?" Which of the following statements should the nurse make? a. "It takes a few months to determine the severity of adverse effects before increasing the dose of medications." b. "It takes a few days of treatment to reach therapeutic blood levels." c. "Medications become effective once the client has resolved their stressors." d. "The brain has to establish a new neuronal pathway in response to medications."

d. "The brain has to establish a new neuronal pathway in response to medications."

A nurse is educating a group of clients on the concept of hardiness. Which of the following statements should the nurse include in the teaching? a. "The foundation of hardiness is the ability to fixate on a stressor in an effort to suppress negative thinking." b. "Hardiness is a personality trait that refers to how a person reacts to the world around them." c. "Hardiness is a genetic predisposition that is non-modifiable." d. "The foundation of hardiness is a positive self-perception and attitudes of hopefulness."

d. "The foundation of hardiness is a positive self-perception and attitudes of hopefulness." A positive self-perception about one's abilities, skills, and capacity to manage stress, along with an attitude of hopefulness is the foundation of hardiness and provides a protective factor when managing stress.

A nurse is facilitating a new parent health and wellness group. One of the group members states, "I have a history of mental illness in my family. Will my child be affected?" Which of the following responses should the nurse make? a. "Through regular health care provider check-ups, you can prevent mental illness from developing." b. "Your family history does not affect the mental health of your child." c. "Mental illness is a product of your environment, not genetics." d. "There are genetic factors of mental health that may put your child at higher risk of developing manifestations of mental illness."

d. "There are genetic factors of mental health that may put your child at higher risk of developing manifestations of mental illness."

A nurse is educating a client about medication therapy. The client asks, "Is there a method of screening for side effects before starting medications?" Which of the following responses should the nurse make about psychiatric pharmacogenomic testing? a. "is effective for determining your maximum tolerable dose." b. "There is testing available that can determine the effectiveness of medications, but not side effects." c. "Current tests only screen for manifestations and not medication efficacy." d. "Your health care provider can order a test to determine efficacy and severity of adverse effects."

d. "Your health care provider can order a test to determine efficacy and severity of adverse effects."

A nurse is caring for a client who recently began taking methylphenidate, a CNS stimulant. Which of the following topics should the nurse prepare to discuss with the client? a. A tolerance to the medication rarely occurs b. An increase in appetite may occur after taking the medication c. The medication should be taken 1 hr before bedtime d. Foods that are known to be high in caffeine should be avoided

d. Foods that are known to be high in caffeine should be avoided

A nurse is caring for a client who is experiencing opiate withdrawal. Which of the following findings should the nurse expect to observe? a. Increased heart rate and blood pressure b. Respiratory depression and excessive drowsiness c. Constipation and pupil constriction d. Goose flesh and diarrhea

d. Goose flesh and diarrhea

A nurse is caring for a client who is experiencing alternating periods of elevated and depressed mood. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepine b. Dopamine antagonist c. Selective serotonin reuptake inhibitor d. Mood stabilizer

d. Mood stabilizer

A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history from a client who is from a different culture than the nurse. Which of the following statements should the nurse make? ·"It seems like your issue is defined by our definition for disease and disorder." ·"I am wondering what you believe the cause of the problem is." ·"Here is a list of coping skills that will be best for your concerns." ·"I think you could benefit from our treatment."

√"I am wondering what you believe the cause of the problem is." While using the CFI, the nurse should elicit the client's perspective of what they believe is causing the problem.

A nurse is caring for a client who states, "I really like you. Can we get together socially after I am discharged?" Which of the following responses should the nurse make? ·"Thank you. You are very kind. However, I am currently in a relationship." ·"I appreciate your comment. However, I am your nurse, and it would be inappropriate for us to engage socially outside of treatment." ·"I am your nurse. You are not allowed to ask me those types of questions." ·"That might be possible, but let's focus on treatment first."

√"I appreciate your comment. However, I am your nurse, and it would be inappropriate for us to engage socially outside of treatment." The client might not be familiar with the boundaries of the professional nurse-client relationship. The nurse should reiterate the boundaries of the relationship while acknowledging the client's statement.

A nurse is interviewing a client who states they are unsure whether they should continue with their medication therapy. Which of the following responses should the nurse make to evoke client motivation? ·"Would you tell me more about what is important to you in your life?" ·"Medications will greatly reduce the occurrence of your symptoms." ·"This might not be the best medication for you, but we can discuss some options that others have found to be helpful." ·"On a scale of 0 to 10, how confident are you that you could adhere to your medication regimen if you tried?"

√"On a scale of 0 to 10, how confident are you that you could adhere to your medication regimen if you tried?" This is a question the nurse would use to evoke client motivation. ·"This might not be the best medication for you, but we can discuss some options that others have found to be helpful." This is an example of a statement that helps the client to focus rather than evoke motivation. ·"Medications will greatly reduce the occurrence of your symptoms." This statement is an example of an expert trap and does not motivate the client. ·"Would you tell me more about what is important to you in your life?" This open-ended question engages the client to discuss topics that are important in their life but does not evoke motivation.

A nurse is interviewing a client who is contemplating a behavior change. Which of the following statements should the nurse make to engage with the client? ·"Tell me about the things that are important to you in your life." ·"I think it would be best for you to gain other perspectives before making any changes." ·"If you prefer, I can offer you some options that others have found to be helpful." ·"You first must decide how important it is for you to make this behavior change."

√"Tell me about the things that are important to you in your life." This open-ended statement engages the client to discuss topics that are important in their life and related to the potential change of behavior.

A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history for a client who is from a culture different than the nurse. Which of the following statements should the nurse make? ·"There are many treatments to relieve symptoms related to your health." ·"You are having issues that are commonly associated with mental illness." ·"Tell me some of the coping skills that have previously helped you." ·"Your issue can be resolved with minimal treatments."

√"Tell me some of the coping skills that have previously helped you." While using the CFI, the nurse should ask the client to discuss what coping skills they have previously used to provide relief from the issues being discussed.

A nurse is interviewing a client who states they are thinking about smoking cessation by using patches. Which of the following responses should the nurse use to focus with the client? ·"What are some important topics in your life?" ·"Smoking increases your chance for developing lung cancer." ·"This might not be the best method for you, but we can discuss some options that others have found to be helpful." ·"On a scale of 0 to 10, how confident are you that you could stop smoking if you tried right now?"

√"This might not be the best method for you, but we can discuss some options that others have found to be helpful." This is an example of a statement that helps the client to focus. ·"What are some important topics in your life? "This open-ended statement engages the client to discuss topics that are important in their life but does not encourage focus. ·"Smoking increases your chance for developing lung cancer." This statement is an example of an expert trap and does not focus the client. ·"On a scale of 0 to 10, how confident are you that you could stop smoking if you tried right now? This statement evokes client motivation rather than focus.

A nurse manager is providing teaching to a group of newly licensed nurses about organizational culture. Which of the following statements by a newly licensed nurse indicates an understanding of organizational culture? ·"This organization believes that each client should be at the center of their own care." ·"Organizational culture refers to reimbursement policies for health care procedures." ·"Clients on an involuntary hold might have certain rights revoked." ·"This organization is a private, for-profit operation."

√"This organization believes that each client should be at the center of their own care." This statement by the nurse represents the beliefs of the organization, which refers to organizational culture.

A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following statements should the nurse make to affirm the client's behavior change? ·"You do not like your medications and would like to try an alternative." ·"You would like to speak to a therapist after treatment." ·"You would like more information. I will get that for you right away." ·"You completed your antibiotic regimen. You are serious about improving your health."

√"You completed your antibiotic regimen. You are serious about improving your health." This statement by the nurse affirms the client's behavior and offers positive reinforcement.

A nurse wants to improve their therapeutic communication by implementing the use of bias-free language. Which of the following actions should the nurse take to provide bias-free language? ·Ask the client how they prefer to be addressed. ·Include the client's sex when ordering a meal tray. ·Withhold religious demographic data when discussing treatment alternatives. ·Record the client's sexuality as "normal" in the plan of care.

√Ask the client how they prefer to be addressed. If the nurse is unsure about how to address a client, they should ask the client for clarification.

A nurse is caring for a client who is from a different culture than them. Which of the following actions should the nurse take to provide culturally competent care? ·Contact an interpreter if the client does not respond to nonverbal communication cues. ·Rely on intuition when interacting with the client. ·Master the communication cues of a single culture. ·Minimize allotted time with the client's spiritual leaders.

√Contact an interpreter if the client does not respond to nonverbal communication cues. The nurse should not hesitate to contact an interpreter if they detect a language barrier or if the client does not respond to nonverbal cues of communication.

A nurse is seeking to improve outcomes in mental health by incorporating technology as a part of primary prevention interventions. Which of the following actions should the nurse take? ·Distribute a video discussing risk factors for suicide and depression at a local high school. ·Record each client's risk factors in an electronic medical record. ·Refer clients to a smartphone application to help reduce manifestations of anxiety. ·Refer at-risk clients to a local health care provider.

√Distribute a video discussing risk factors for suicide and depression at a local high school. This action by the nurse represents a strategy for incorporating technology as a primary prevention intervention.

A nurse is admitting a new client. Which of the following actions should the nurse take during the orientation phase of the nurse-client relationship? ·Recognize educational needs. ·Establish boundaries. ·Affirm client attitude toward treatment. ·Provide community resource referrals.

√Establish boundaries. In the orientation phase, the nurse sets the tone for the relationship by setting boundaries and developing mutual goals.

A nurse is interviewing a client who is irritable and agitated. Which of the following actions should the nurse take to portray engagement with the client? ·Touch the client's upper arm. ·Avoid making eye contact. ·Sit directly across from the client. ·Give a slight nod throughout the interview.

√Give a slight nod throughout the interview. To avoid appearing too relaxed, the nurse should give a slight nod or slightly lean forward to exhibit engagement.

A nurse is researching methods of incorporating technology in their nursing practice. Which of the following strategies should the nurse use to incorporate technology in nursing care? ·Implement a client-centered self-schedule smartphone application. ·Incorporate therapeutic communication during each client appointment. ·Allow clients to self-disclose religious affiliations. ·Include bias-free language in educational brochures.

√Implement a client-centered self-schedule smartphone application. The nurse can utilize electronic health records, educational videos, and smartphone applications to improve mental health care outcomes.

A nurse is researching methods of incorporating technology in their nursing practice. Which of the following strategies should the nurse use to incorporate technology in nursing care? ·Implement a video conferencing policy for clients in rural locations. ·Include the client's spiritual leader during discharge planning. ·Allow the client to disclose gender identity upon admission. ·Provide education discussing the importance of treatment adherence.

√Implement a video conferencing policy for clients in rural locations. The nurse could utilize video conferencing to improve equity for clients in rural locations.

A nurse is participating in an interdisciplinary team meeting for clients on the unit. Which of the following actions should the nurse recommend to improve inclusion among the treatment team? ·Integrate complementary and alternative therapies for clients. ·Provide vouchers for free or low-cost medical transportation. ·Include discussion of the clients' spiritual needs in team meetings. ·Suggest that clients be identified by their diagnoses to protect confidentiality.

√Include discussion of the clients' spiritual needs in team meetings. Recommending this action supports inclusion. Inclusion refers to the ability of all care team members, including the clients, to voice their concerns with treatment and influence the decision-making process based on their needs.