ATI Mental Health Nursing Review
A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."
A Carbamazepine is used during withdrawal to decrease the risk for seizures
A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. Administer the next dose of lithium carbonate as scheduled B. Prepare for administration of aminophyline C. Notify the provider for possible increase in the dosage of lithium carbonate D. Request a stat repeat of the client's lithium blood level
A During a manic episode, the lithium blood level should be 0.8 to 1.4 mEq/L. It is appropriate to administer the next dose as scheduled.
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply) A. To assess cognitive ability, I should ask the client to count backward by sevens. B. To assess affect, I should observe the client's facial expression. C. To assess language ability, I should instruct the client to write a sentence. D. To assess remote memory, I should have the client repeat a list of objects. E. To assess the client's abstract thinking, I should as the client to identify our most recent presidents.
A, B, C
A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply.) A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be prescribed and dispensed by an approved treatment center."
A, B, C, E
A nurse is working in a community mental health facility. Which of the following services are appropriate for clients to receive? (Select all that apply). A.Educational groups B.Medication dispensing programs C.Individual counseling programs D.Detoxification programs E.Family Therapy
A, B, C, E A.CORRECT: Educational groups are services provided in a community mental health facility. B. CORRECT: Medication dispensing programs are services provided in a community mental health facility. C. CORRECT: Individual counseling programs are services provided in a community mental health facility. E. CORRECT: Family therapy is a service provided in a community mental health facility.
A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following are appropriate to include in the plan of care? (Select all that apply.) A. Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation
A, B, D
A nurse is teaching the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Seizures B. Agitation C. Photophobia D. Dry mouth E. Irregular pulse
A, B, E
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following should the charge nurse identify as being effectively treated by conventional antipsychotics? (Select all that apply.) A. Auditory hallucinations B. Withdrawal from social situations C. Delusions of grandeur D. Severe agitation E. Anhedonia
A, C, D
A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states "I grind my teeth during the night, which causes pain in my mouth". The nurse should identify 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 anti anxiety medication E. increasing the dose of paroxetine
A, C, D
A nurse is teaching a client who has a new prescription for imipramine (Tofranil) how to minimize anticholinergic effects. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Void just before taking the medication. B. Increase the dietary intake of potassium. C. Wear sunglasses when outside. D. Change positions slowly when getting up. E. Chew sugarless gum.
A, C, E A. Voiding just before taking the medication will help minimize the anticholinergic effects of urinary hesitancy or retention. C. Wearing sunglasses when outside will help minimize the effect of photophobia E. Chewing sugarless gum will help minimize effect of dry mouth
A nurse is planning care for a client following surgical implantation of a vagus nerve stimlation (VNS) device. The nurse should plan to monitor for which of the following adverse effects? (select all that apply) A. Voice changes B. Seizure activity C. Disorientation D. Dysphagia E. Neck pain
A, D, E
A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of his alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. This form of treatment is an example of which of the following? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy
A. Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior.
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions is appropriate to include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries
A. Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase.
A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Eat a diet high in fiber. B. Check temperature daily. C. Take medication first thing in the morning before eating. D. Add extra calories to the diet as between‑meal snacks
A. Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use
A charge nurse is discussing mirtazapine (Remeron) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I will need to monitor the client for hyponatremia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."
A. Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine.
Nurse is discussing routine follow‑up needs with a client who has a new prescription for valproate. the nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT & LDH B. Creatinine & BUN C. WBC & Granulocyte counts D. Serum sodium & potassium
A. Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity
A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication? A. Offering advice B. Reflecting meaning C. Listening attentively D. Giving information
A. Advice tends to interfere with the client's ability to make personal decisions and choices.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all that apply.) A. "client ate most of his breakfast." B. "client was offered 8 oz of water every hr." C. "client shouted obscenities at assistive personnel." D. "client received chlorpromazine 15 mg by mouth at 1000." E. "client acted out after lunch.
B, C, D b. CORRECT: how much water was offered and how often it was offered is objective data that the nurse should document when caring for a client in mechanical restraints. c. CORRECT: a description of the client's verbal communication is objective data that the nurse should document when caring for a client in mechanical restraints. d. CORRECT: the dosage and time of medication administration is objective data that the nurse should document when caring for a client in mechanical restraints
A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply.) A. Decreased level of consciousness B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing
B, C, E
A nurse is planning group therapy for clients dealing with bereavement. Which of the following should the nurse include in the initial phase? (Select all that apply) A. Encourage the group to work toward goals. B. Define the purpose of the group. C. Discuss termination of the group. D. Identify informal roles of members within the group. E. Establish an expectation of confidentiality within the group.
B, C, E
A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply.) A. An adverse effect of this medication is CNS depression. B. Administer the medication in the morning. C. Monitor for weight loss while taking this medication. D. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop. E. This medication blocks the blocking the synaptic reuptake of serotonin in the brain.
B, C, E
A nurse is caring for a client who is taking phenelzine (Nardil). For which of the following adverse effects should the nurse observe? (Select all that apply.) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Headache E. Bruxism
B, D
Nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. the nurse should include which of the following manifestations in the teaching? (select all that apply.) A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus
B, D
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client? (select all that apply) A. Reassure the client that everything will be okay. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed-ended questions.
B, D B. CORRECT: Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. D. CORRECT: Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? select all that apply A. hypothermia B. hallucinations C. muscular flaccidity D. diaphoresis E. agitation
B, D, E
A nurse is planning a peer group discussion about the diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following information is appropriate to include in the discussion? (select all that apply) A. The DSM-5 includes client education handouts for mental health disorders B. The DSM-5 establishes diagnostic criteria for individual mental health disorders C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders. D. The DSM-5 assists nurses in planning care for clients who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders.
B, D, E
A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (Select all that apply.) A. Somnolence B. Yellowing skin C. Increased appetite D. Fever E. Malaise
B, D, E
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who says he is becoming more anxious during group therapy D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months
B. An ACT group works with clients who are nonadherent with traditional therapy, such as the client in a home setting who keeps "forgetting" his injection.
Nurse is caring for a client who is prescribed lithium therapy. the client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."
B. Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk for lithium toxicity
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services. B. Identify the client's perception of their mental health status. C. Include the client's family in the interview. D. Teach the client about their current mental health disorder.
B. Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important information bout the client's psychosocial history.
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."
B. Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder.
A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction
B. Manipulation: the dysfunctional behavior of using dishonesty to support an individual agenda. (Placation: the dysfunctional behavior of taking responsibility for problems to keep peace among family members. Blaming: the dysfunctional behavior of blaming others to shift focus away from the individual's own inadequacies. Distraction: the dysfunctional behavior of inserting irrelevant information during attempts at problem solving.)
A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client is perspiring and pale, has a respiratory rate 30/min, and says, "I don't quite understand what you're trying to tell me." The nurse should assess the client's anxiety as which of the following? A.Mild B.Moderate C.Severe D.Panic
B. Moderate anxiety decreases problem-solving and may hamper one's ability to understand information. Vital signs may increase somewhat, and the person is visibly anxious.
A charge nurse is discussing transcranial magnetic stimulation (TMS) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "TMS is indicated for clients whose depression is not relieved by medication." B. "I will provide postanesthesia care following TMS." C. "TMS is usually performed as an outpatient procedure." D. "I will schedule the client for daily TMS treatments for the first several weeks."
B. Postanesthesia care is not necessary because the client does not receive anesthesia and is alert during the procedure.
A nurse is providing teaching to a client who has a new prescription for amitriptyline (Elavil). Which of the following client statements indicates understanding of the teaching? A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash." B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."
B. Sedation is an adverse effect of amitriptyline during the first few weeks of therapy.
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." Which of the following defense mechanisms is the client using? A.Reaction formation B.Denial C.Displacement D.Sublimation
B. This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short‑staffed, and the client frequently fights with other clients. the nurse's actions are an example of which of the following torts? A. invasion of privacy B. False imprisonment C. assault D. Battery
B. A civil wrong that violates a client's civil rights is a tort. in this case, it is false imprisonment, which is the confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the convenience of staff.
A nurse is evaluating a client's understanding of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching? A. "Taking this medication will help reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medicine." D. "Each dose of this medication should be placed under my tongue to dissolve."
B. Clonidine commonly causes clients to experience dry mouth. Chewing sugarless gum is an effective method to address this adverse effect.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. notify the nurse manager. B. tell the nurse to stop discussing the behavior. C. Provide an in‑service program about confidentiality. D. complete an incident report
B. The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. the first action the nurse should take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurse of telling him what to do just like his ex-partner. C. The client reminds the nurse of a friend who died from a substance toxicity. D. The client becomes angry and threatens to engage in self-harm.
B. When a client views the nurse as having characteristics of another person who has been significant to their personal life, this indicates transference.
A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority? A. administer flumazenil B. identify the client's level of orientation C. infuse IV fluids D. prepare the client for gastric lavage
B. when taking the nursing process approach to client care the initial step is assessment. Identifying the client's level of orientation is the priority action.
A nurse is working on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following? A. Triangulation B. Group process C. Subgroup D. Hidden agenda
C A subgroup is a small number of people within a larger group who function separately from that group (Triangulation: third party is drawn into a relationship with two members whose relationship is unstable. Group process: the verbal and nonverbal communication that occurs within the group during group sessions. Hidden agenda: when some group members have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of the group.)
A nurse is caring for a client who takes ziprasidone (Geodon). The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (Select all that apply.) A. Olanzapine (Zyprexa) B. Quetiapine (Seroquel) C. Aripiprazole (Abilify) D. Clozapine (Clozaril) E. Paliperidone (Invega)
C, D
A nurse is assessing a client immediately following an electroconvulsive therapy (ECT) proceedure. Which of the following are expected findings? (Select all that apply) A. Hypotension B. Paralytic ileus C. Memory loss D. Nausea E. Tachycardia
C, D, E
A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should anticipate prescriptions for which of the following medications to promote long‑term abstinence from alcohol? (Select all that apply.) A. Lorazepam B. Diazepam C. Disulfiram D. Naltrexone E. Acamprosate
C, D, E
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following are appropriate to include in the discussion? (Select all that apply) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established.
C, D, E. C. CORRECT: A therapeutic nurse-client relationship is goal-directed D. CORRECT: A therapeutic nurse-client relationship encourages positive behavioral change. E. CORRECT: A therapeutic nurse-client relationship has an established termination date.
A nurse in an acute mental health facility is caring for a client who has a severe mental illness and soonwill be ready for discharge but still requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following should the nurse suggest as appropriate follow-up care? A.Receiving daily care from a home health aide B.Having a weekly visit from a nurse case worker C.Attending a partial hospitalization program D.Visiting a community mental health center on a daily basis
C. A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present.
A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A. A member who praises input from other members. B. A member who follows the direction of other members. C. A member who brags about accomplishments. D. A mbmer who evaluates the group's performance toward a standard.
C. An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals. (Maintenance role: individual who praises the input of others / is a follower. Task role: individual who evaluates the group's performance.)
A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone (Fanapt). Which of the following client statements indicates understanding of the teaching? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."
C. Antipsychotic medications have a high risk for significant weight gain.
A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements by the nurse is appropriate? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."
C. Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit.
A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions? A. Observes group techniques without interfering with the group process. B. Discusses a technique and then directs members to practice the technique. C. Asks for group suggestions of techniques and then supports discussion. D. Suggests techniques and asks group members to reflect on their use.
C. Democratic leadership: supports group interaction and decision making to solve problems. (Laissez-faire: allows the group process to progress without any attempt by the leader to control the direction of the group. Autocratic leadership: controls the direction of the group.)
A nurse is leading a peer group discussion about the indications for electroconvulsive therapy (ECT). Which of the following is appropriate to include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to substance use disorder C. Bipolar disorder with rapid cycling D. Dysthymic disorder
C. ECT is indicated for the treatment of bipolar disorder with rapid cycling.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression
C. Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness.
A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following is appropriate when implementing this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator. C. Gradually expose the client to an elevator while practicing relaxation techniques .D. Stay with the client in an elevator until his anxiety response diminishes.
C. Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response.
A nurse is reviewing the medical record of a client who has a new prescription for bupropion (Wellbutrin) for depression. Which of the following findings is the highest priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression. B. The client currently smokes 1.5 packs of cigarettes per day. C. The client had a motor vehicle crash last year and sustained a head injury. D. The client has a BMI of 25 and has gained 10 lb over the last year.
C. The greatest risk to the client is the development of seizures. Bupropion can lower the seizure threshold and should be avoided by clients who have a history of head injury. This information is the highest priority to report to the provider.
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements by the nurse is appropriate? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one."
C. This statement is an empathetic response that attempts to understand the client's feelings
A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use o f this medication? A. "I will take the medication at bedtime" B. "I will follow a low-sodium diet while taking this medication" C. " I will need to discontinue this medication slowly" D. "I will be at risk for weight loss with long term use of this medication"
C. When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal syndrome
A nurse is caring for several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first? A.A client who recently burned her arm while using a hot iron at home B.A client who requests that her antipsychotic medication be changed due to some new side effects C.A client who says he is hearing a voice that tells him he is not worthy of living anymore D.A client who tells the nurse he experienced symptoms of severe anxiety before and during a job interview
C. A client who hears a voice telling him he is not worthy is at greatest risk for self-harm, and the nurse should visit this client first.
A nurse in an emergency mental health facility is caring for a group of clients. the nurse should identify that which of the following clients requires a temporary emergency admission? A. a client who has schizophrenia with delusions of grandeur B. a client who has manifestations of depression and attempted suicide a year ago C. a client who has borderline personality disorder and assaulted a homeless man with a metal rod D. a client who has bipolar disorder and paces quickly around the room while talking to himself
C. A client who is a current danger to self or others is a candidate for a temporary emergency admission.
A nurse is conducting therapy with several clients and their families. Effective communication with clients and families is based on: A. discussing in-depth topics with which the client feels comfortable. B. using silence to avoid unpleasant or difficult topics. C. attending to verbal and nonverbal behaviors. D. requiring the client and family to ask for feedback.
C. Attending to verbal and nonverbal behaviors is necessary for effective communication.
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications? A. Chlorpromazine (Thorazine) B. Thiothixene (Navane) C. Risperidone (Risperdal) D. Haloperidol (Haldol)
C. Second gen antipsychotics are effective in treating negative symptoms of schizophrenia
A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching? A. Chew the gum for no more than 10 min. B. Rinse out the mouth immediately before chewing the gum. C. Avoid eating 15 min prior to chewing the gum. D. Use of the gum is limited to 90 days.
C. The client should avoid eating or drinking 15 minutes prior to and while chewing the gum.
A client tells a nurse "don't tell anyone, but i hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and his roommate closely. C. tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention to do so.
C. The information presented by the client is a serious safety issue that the nurse must report to the health care team. using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue.
A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting. B. The nurse examines her own personal feelings about clients who have anorexia nervosa. C. The nurse asks the client about her body image perception. D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents
C. The nurse's one-on-one communication with the client is an example of interpersonal communication.
Nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the priority to report to the provider? A. "My mother has diabetes that is controlled by her diet." B. "My mother recently completed a course of prednisone for acute bronchitis." C. "My mother received her flu vaccine last month." D. "My mother is currently on furosemide for her congestive heart failure."
D Diuretics are contraindicated for use with lithium due to the risk for toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider.
A nurse is providing teaching for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I will have seizures lasting 1 1/2 to 2 minutes during ECT." D. "I will receive a muscle relaxant to protect me from injury during ECT."
D. ECT: for major depressive disorder not responsive to meds, ↓ incidence and relapse of depression, causes seizures of 25-60 seconds.
A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I may begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."
D. Free association is the spontaneous uncensored verbalization of whatever comes to a client's mind.
A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions D. Monitor the client for adverse effects of medications.
D. Monitoring for adverse effects of medications is an example of psychobiological intervention
A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A. Apply the patch once daily at bedtime. B. Place the patch carefully in a trash can after removal. C. Apply the transdermal patch to the anterior waist area. D. Remove the patch each day after 9 hr.
D. The transdermal patch is applied once daily in the morning and is removed after 9 hours.
A nurse is teaching a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse provide? A. three to six weeks of treatment is required to achieve therapeutic benefit B. combining alcohol with alprazolam will produce a paradoxical response C. alprazolam has a lower risk for dependence than other anti-anxiety medications D. report confusion as a potential indication of toxicity
D. confusion is a potential indication of alprazolam toxicity that the client should report to the provider
A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating
D. Restating allows the nurse to repeat the main idea expressed.
A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. I think your child is getting better. What have you noticed? B. I'm sure everything will be okay. It just takes time to heal. C. I'm not sure what's wrong. Have you asked the doctor about your concerns? D. I understand you're concerned. Let's discuss what concerns you specifically.
D. This therapeutic response reflects upon and accepts the caregivers feelings and it allows them to clarify what they are feeling.
A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication? A. Personal space B. Posture C. Eye contact D. Intonation
D. Intonation Personal space, posture, and eye contact is a part of nonverbal behavior.• Intonation is the tone of one's voice and can communicate a variety of feelings.
