ATI RN Mental Health Online Practice 2023 A

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? 1. The client is interested in what the nurse is saying 2. The client is attempting to manipulate the nurse 3. The client is physically attracted to the nurse 4. The client is seeking acceptance by the nurse

Correct - 1. The client is interested in what the nurse is saying The client's posture and eye contact demonstrate an interest in the interview and what the nurse is saying

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as contraindication for receiving clozapine? 1. WBC count 2,500 2. Hgb 11.5 3. Platelets 150,000 4. RBC count 3.5

Correct - 1. WBC count 2,500 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? 1. "I'm relieved now that my financial affairs are in order." 2. "It is easier to talk about my feelings now." 3. "Suddenly I have enough energy to do anything I want." 4. "Thank you for always taking such good care of me."

Correct - 2. "It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome *When clients who have depression verbalize getting their affairs in order, or suddenly have more energy are at an increased risk of suicide. Clients who have depression often show an appreciation for loved ones when they are contemplating suicide

A nurse is caring for a client who has a personality disorder. For each potential nursing intervention, click to specify if the potential intervention is Anticipated, Nonessential, or Contraindicated for the client. Potential Intervention: 1. Administer Haloperidol 2mg IM 2. Hold next dose of Buspirone 3. Request change of diet to mechanical soft 4. Request prescription for Digoxin 1mg IV Bolus Stat 5. Calmly approach client and state "You seem agitated. Let's sit quietly and talk about it." Exhibit 1 Nurses' Notes Day 1, 0700​: Talkative, well-groomed. States they are "looking forward to divorcing partner number four" because they have "found my next partner." Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode."​ Day 2, 1000​: Restless for past 2 hrs., pacing from bedroom to dayroom and mumbling to self Argued with nurse this morning about attend

Correct = 1. Administer Haloperidol 2mg IM = Anticipated *The client is agitated and displaying manifestations of aggression. Therefore, haloperidol is anticipated. 2. Hold next dose of Buspirone = Contraindicated *The nurse should plan to administer buspirone to decrease the client's anxiety. 3. Request change of diet to mechanical soft = Nonessential *The nurse should plan to maintain the client's diet as prescribed. The client does not exhibit manifestations of difficulty swallowing or chewing. 4. Request prescription for Digoxin 1mg IV Bolus Stat = Contraindicated *The nurse should identify that the client's heart rate is within the expected reference range. Digoxin is contraindicated for this client. 5.. Calmly approach client and state "You seem agitated. Let's sit quietly and talk about it." = Anticipated *The nurse should use therapeutic communication to promote rapport and reduce the client's anxiety.

A nurse is caring for a client who has a personality disorder. The nurse is caring for a client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined. Potential Assessment Findings: 1. Client attempts to bite nursing staff when offered water 2. Client follows instructions of the nurse 3. Client is silent and glaring at staff 4. Client verbalizes precipitating factors to violent outbursts Exhibit 1 Nurses' Notes Day 1, 0700: Talkative, well-groomed. States they are "looking forward to divorcing partner number four" because they have "found my next partner." Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2, 1000​: Restless for past 2 hr., pacing from bedroom to dayroom and mumbling to self Argued wi

Correct = 1. Client attempts to bite nursing staff when offered water = Declined *The client is exhibiting worsening aggressive and violent behavior by attempting to bite nursing staff members. 2. Client follows instructions of the nurse = Improved *The client is exhibiting control over their behavior and is able to follow instructions. 3. Client is silent and glaring at staff = No Change *The client is still exhibiting agitation and nonverbal aggressive behaviors. 4. Client verbalizes precipitating factors to violent outbursts = Improved *The client is able to verbalize and identify factors that contributed to the violent behavior.

A nurse is caring for a newly admitted Client. For each potential finding, click to specify if the finding is consistent with positive or negative symptoms of schizophrenia. Assessment Finding: 1. Delusions of Grandeur 2. Clang Associations 3. Catatonia 4. Alogia 5. Withdrawal from Social Activities Exhibit 1 Vital Signs 0800: BP = 110/78 HR = 76 RR - 18 T = 98.6 1200: BP = 116/80 HR = 88 RR = 20 T = 100.4 Exhibit 2 Medical History Client admitted following episodes of hallucinations and delusions, according to family member. Outpatient treatment has not been effective. Client has been unable to maintain their job. Friends state the client has been acting "weird." Family members have noticed the client no longer maintains a clean and neat appearance, which is unusual for them. Exhibit 3 Nurses' Notes 0800: Client oriented to unit and introduced to staff. Client is quiet and withdrawn. Mumbles to self while look

Correct = 1. Delusions of Grandeur = Positive Symptom 2. Clang Associations = Positive Symptom 3. Catatonia = Positive Symptom *Delusions of grandeur, clang associations, and catatonia are potential assessment findings of positive symptoms of schizophrenia. Other positive symptoms include hallucinations, paranoia, and disorganized/bizarre thoughts, behaviors, or speech. 4. Alogia = Negative Symptom 5. Withdrawal from Social Activities = Negative Symptom *Alogia and withdrawal from social activities are potential assessment findings of negative symptoms of schizophrenia. Other negative symptoms include lack of goal-directed behavior, social discomfort, and the inability to enjoy activities.

A nurse is caring for a client who has a personality disorder. Select the 6 findings in the client's medical record that are manifestations of the client's diagnosed personality disorder. 1. Stealing money from family to cover credit card charges 2. Exercises twice a week 3. Anxious if left alone 4. Same job for 12 years 5. Well-nourished female 6. Hypersexualization 7. Well-groomed 8. Married multiple times 9. Incidences of self-injury 10. Physical altercations Exhibit 1 Graphic Record Day 1, 0715​: T = 97.2° F, HR = 86, RR = 16, BP = 112/76 Exhibit 2 History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and Hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: bord

Correct = 1. Stealing money from family to cover credit card charges *The nurse should identify that stealing money is an impulsive behavior, which is a manifestation of borderline personality disorder. 3. Anxious if left alone *The nurse should identify that the client's anxiety about being left alone is due to fear of separation, which is a manifestation of borderline personality disorder. 6. Hypersexualization *The nurse should identify that hypersexualization is an impulsive, self-damaging behavior, which is a manifestation of borderline personality disorder. 8. Married multiple times *The nurse should identify that unstable romantic relationships are a manifestation of borderline personality disorder. 9. Incidences of self-injury *The nurse should identify that self-injury is a manifestation of borderline personality disorder. Self-destructive behaviors, such as cutting, are common with this disorder. 10. Physical altercations *The nurse should identify that engaging in physical altercations is a manifestation of borderline personality disorder.

A nurse is caring for a client who has a personality disorder. For each potential provider's prescription, click to specify if the prescribed therapy is expect with Obsessive Compulsive Disorder, Dementia, or Borderline Personality Disorder. Each therapy can support more than one disease process. Prescribed Therapy: 1. Systematic Desensitization 2. Validation Therapy 3. Dialectical Behavioral Therapy 4. Donepezil 5mg PO Daily 5. Fluoxetine 20mg PO Daily Exhibit 1 History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and Hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-

Correct = 1. Systematic Desensitization = OCD *This therapy provides relaxation techniques to address a client's fears. 2. Validation Therapy = Dementia *This therapy provides reorientation and validation for clients who experience a misperception of reality. 3. Dialectical Behavioral Therapy = Borderline Personality Disorder *This therapy provides cognitive and behavioral techniques for clients who are suicidal and have borderline personality disorder. 4. Donepezil 5mg PO Daily = Dementia *This therapy is a cholinesterase inhibitor used to treat cognitive impairment. 5. Fluoxetine 20mg PO Daily = OCD and Borderline Personality Disorder *This therapy is an SSRI used to reduce self-injurious behavior and decreases repetitive behavior.

A nurse on a mental health unit is caring for a client who has schizophrenia. After reviewing the client's medical record, the nurse should notify the provider of which of the following findings? SELECT THE 5 UNEXPECTED FINDINGS THAT REQUIRE NOTIFICATION OF THE PROVIDER 1. Temperature 2. Blood pressure 3. Bowel sounds 4. WBC count 5. ANC level 6. Myalgia 7. Heart rate Exhibit 1 Nurses' Notes 1200:​ Female client diagnosed with schizophrenia approximately 2 years ago after experiencing psychosis. Client has taken chlorpromazine and loxapine with minimal improvement in positive and negative symptoms. Client attends a local community college and works at a grocery store. Exhibit 2 Vital Signs 0800: BP = 112/66 HR = 88 RR = 16 T = 99.9 O2 = 98% RA 1200: BP = 104/60 HR = 106 RR = 20 T = 100.9 O2 = 97% RA Exhibit 3 Diagnostic Results 0630:​ WBC count 5,100/mm3 (5,000 to 10,000/mm3) RBC count 5.0 million/mm3 (4

Correct = 1. Temperature 3. Bowel Sounds 5. ANC level 6. Myalgia 7. Heart rate *When taking actions, the nurse should identify an elevated temperature, hypoactive bowel sounds, a decreased ANC level, myalgia along with an increased heart rate can be adverse effects of the medication clozapine. Therefore, the nurse should report these findings to the client's provider.

A nurse is caring for a client who has impaired cognition A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client Potential Intervention: 1. When addressing the client, approach them from the front when possible 2. Use a vest restrain to keep the client in a medical recliner 3. Ensure the bed is kept at a working height for the nurse 4. Provide the client with high-calorie protein drinks hourly 5. Give directions to the client slowly and in a moderate tone of voice 6. Decrease the sensory stimulation 7. Keep the lights off in the client's bedroom and bathroom at night 8. Assign the client to a room near the nurses' station Exhibit 1: Medical History Day 1, 0800: Client treated for UTI 8 months ago Day 3, 0830: Client fell getting out of bed to go to the ba

Correct = 1. When addressing the client, approach them from the front when possible = Anticipated. *A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote aggressive behavior in the client. 2. Use a vest restraint to keep the client in a medical recliner = Contraindicated. *The client has the right to be free from the use of restraints except in the case of an emergency. 3. Ensure the bed is kept at a working height for the nurse = Contraindicated. *The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the client does fall. 4. Provide the client with high-calorie protein drinks hourly = Nonessential. *This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has mania with this type of dietary supplement. 5. Give directions to the client slowly and in a moderate tone of voice = Anticipated. *Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause the client to feel uncomfortable and can even cause feelings of anger. 6. Decrease sensory stimulation = Anticipated. *A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair client safety. 7. Keep the lights off in the client's bedroom and bathroom at night = Contraindicated. *This can increase the client's risk for falls. Keeping a light on can decrease wandering. 8. Assign the client to a room near the nurses' station = Anticipated. *This promotes client safety by allowing staff to observe the client frequently.

A nurse is caring for a client who has a panic disorder. Click to highlight the findings in the medical record that indicate maladaptive uses of defense mechanisms. 1. Eager to participate in group therapy and is looking forward to group exercise class later this afternoon. 2. Returned from exercise class in agitated state. 3. Client tells the nurse, "That exercise instructor was one of my favorite people here. We had so much in common. But now I know their true nature. She's evil!" Exhibit 1 Medication Administration Record​ 0900:Fluoxetine 40 mg PO daily Exhibit 2 Nurses' Notes 0900: Engaged with other clients. Consumed 90% of breakfast. Eager to participate in group therapy and is looking forward to group exercise class later this afternoon. 1400: Returned from exercise class in agitated state. According to other clients, the instructor had to tell the client to stop interrupting during the class. Client te

Correct = 2. Returned from exercise class in agitated state. 3. Client tells the nurse, "That exercise instructor was one of my favorite people here. We had so much in common. But now I know their true nature. She's evil!" *When recognizing cues, the nurse should identify the client returning from exercise and being in an agitated state is the client demonstrating the maladaptive use of a deference mechanism. The nurse should also identify when the client tells them that the exercise instructor was one of their favorite people and had so much in common, but no one sees their true nature and that she is evil is the client demonstrating the maladaptive use of splitting. Splitting is the inability to combine positive qualities of a person into a unified likeness.

A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a selegiline 12mg transdermal patch once daily. Complete the follow sentence by using the list options. Dropdown 1: "The Client is at risk of developing ________ 1. Extrapyramidal Side Effects (EPS) 2. Hypertensive Crisis 3. Dry Mouth Dropdown 2: "due to ________ 4. Consuming foods high in Tyramine 5. Taking an antipsychotic medication 5. Anticholinergic Reaction Exhibit 1 Nurses' Notes Tuesday: Client diagnosed with major depressive disorder 15 years ago. Visits clinic twice a week for outpatient group therapy with social worker and follow-up with nurse. Client actively participates in therapy. Acknowledges that relationship with family members has improved and there are fewer verbal altercations. Thursday: Client presents with irritability, diaphoresis, and severe headache, and states, "I am really feeling bad. My heart i

Correct = Dropdown 1: 2. Hypertensive Crisis *Selegiline is a MAOI medication used to treat depression. Foods that contain tyramine, such as aged cheese, yeast, and smoked or aged meats, should not be consumed because this can cause a hypertensive crisis. Other manifestations of hypertensive crisis include chest pain, severe headache, nausea and vomiting, tachycardia, palpitations, and fever. Dropdown 2: 4. Consuming foods high in Tyramine *The nurse should identify that consuming foods high in tyramine while taking an MAOI can lead to a hypertensive crisis. Selegiline is a MAOI medication used to treat depression. Foods that contain tyramine, such as aged cheese, yeast, and smoked or aged meats, should not be consumed. Other manifestations of hypertensive crisis include chest pain, severe headache, nausea and vomiting, tachycardia, palpitations, and fever.

A nurse is caring for a client who has a personality disorder. Complete the following sentence by using the lists of options. Dropdown 1: "The client is at risk for developing ________ 1. Hypertension 2. Violent Behavior 3. Anemiaterm-52 4. Anorexia Dropdown 2: "as evidenced by the client's ________ 5. Heart Rate 6. Hematocrit Level 7. Increased Agitation 8. Regular Exercise Exhibit 1 History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and Hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. Exhibit 2 Prov

Correct = Dropdown 1: 2. Violent Behavior *The client is at risk for developing violent behavior due to increased anxiety and agitation and a history of physical altercations. The nurse should monitor the client for signs of escalating agitation and aggressive behaviors. Dropdown 2: 7. Increased Agitation: *The client's history of physical altercations and statement of irritability indicate that the client is experiencing increased agitation.

A nurse is caring for a client who has post traumatic stress disorder and a new prescription for sertraline. A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication? SELECT ALL THAT APPLY 1. Temperature 2. Heart rate 3. Sodium level 4. Diaphoresis 5. Insomnia 6. Headache 7. Glucose level 8. Potassium level 9. Blood pressure Exhibit 1 Vital Signs Day 1, 0830 T = 97.9 HR = 92 RR = 22 BP = 120/70 Day 3, 1000 T = 101.7 HR = 98 RR = 24 BP = 140/86 Exhibit 2 Diagnostic Results Day 1, 0830: Sodium 138 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 4.5 mEq/L) Glucose 88 mg/dL (74 to 106 mg/dL) Day 4, 1000: Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 4.0 mEq/L (3.5 to 4.5 mEq/L) Glucose 77 mg/dL (74 to 106 mg/dL) Exhibit 3 Nurses' Notes Day 1, 0830: • Client is request

Correct = 1. Temperature 3. Sodium level 4. Diaphoresis 5. Insomnia 6. Headache 9. Blood pressure *When taking actions, the nurse should identify that an increased temperature, decreased sodium level, diaphoresis, insomnia, headache, and elevated blood pressure can be adverse effects of the medication sertraline. Therefore, the nurse should report these findings to the provider.

A nurse is caring for a client who has a personality disorder. The nurse is caring for the client. Which of the following actions should the nurse take? SELECT ALL THAT APPLY 1. Document the client's condition every 30 min. 2. Maintain continuous observation of the client while in restraints. 3. Remove two restraints at a time as the client regains control. 4. Maintain the client NPO during time in restraints. 5. Ensure the client is in prone position. 6. Conduct debriefing with the client and other staff. Exhibit 1 Medication Administration Record Day 1:​ Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Day 2: Buspirone 7.5mg PO at 0800 Bacitracin Ointment applied to leg and arm wounds at 0800 Haloperidol 2mg IM left ventrogluteal at 1205 Exhibit 2 History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior

Correct = 2. Maintain continuous observation of the client while in restraints. *The nurse should ensure a staff member remains with the client continuously while the client is in restraints. 6. Conduct debriefing with the client and other staff. *The nurse should conduct debriefing with other staff members to indicate the necessity of the intervention and to ensure that quality care was provided. The nurse should conduct a debriefing with the client to discuss their thoughts about what contributed to the intervention and strategies for crisis prevention in the future. **The nurse should document the client's condition every 15 Minutes while the client is in restraints. The nurse should remove one restrain at a time with assistance from other staff members as necessary as the client regains control. The nurse should provide nutrition and hydration for the client, as well as address eliminations needs while the client is in restraints. The nurse should place the client in a comfortable position where aspiration is prevented. The client should never be restrained in a prone position.

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? 1. "I will update the plan of care as a client's manifestations of depression change." 2. "Each nurse will develop a separate plan of care for each client who has depression." 3. "I will use the same plan of care and interventions for each client who has depression." 4. "An assistive personnel can use the plan of care for client teaching."

Correct = 1. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change. *Each client should have one individualized plan of care that is initiated upon admission. One that addresses the unique medical diagnosis, nursing care needs, and discharge plan; and is used by all interprofessional team members. *an RN is qualified to provide client teaching

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? 1. "If you do my homework for me, I won't bother you for the rest of the day." 2. "Mom is always upset." 3. "It's not the children's fault. It's mine." 4. "It's your fault that we're having problems as a family."

Correct = 1. "If you do my homework for me, I won't bother you for the rest of the day." This is an example of manipulative behavior. It is an example of manipulation when the family member uses a behavior to get what they desire rather than directly asking for what they want.

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? 1. Emotional lability 2. Self-sacrificing 3. Suspicious of others 4. Grandiosity

Correct = 1. Emotional Lability Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances. *Self-Sacrificing, Excessively Clingy and Submissive: Features of Dependent Personality Disorder *Suspicious of Others, Project Blame onto Others, Hostile and Violent: Features of Paranoid Personality Disorder *Grandiosity, Exploitive, Filled with Rage, and Sensitive to Criticism: Features of Narcissistic Personality Disorder

A nurse is admitting a client who has anorexia nervosa and is at 60% of their ideal body weight. Which of the following interventions should the nurse include in the plan of care? 1. Encourage the client to drink 125 mL of fluid each hour while awake. 2. Allow the client to eat independently in their room. 3. Weigh the client twice weekly. 4. Measure the client's vital signs once each day.

Correct = 1. Encourage the client to drink 125 mL of fluid each hour while awake. The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration. The nurse should remain with the client during meals to prevent the client from purging or hiding food in clothing. For the first week of treatment, the nurse should weigh the client daily upon waking, after voiding, and before having anything to drink or eat. Initially, the nurse should measure the client's vital signs three times each day until the client's weight increases and cardiovascular status improves.

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take? 1. Gather supplies for endotracheal intubation. 2. Administer a beta blocker intravenously. 3. Position the client in a low-Fowler's position. 4. Place a cooling blanket over the client.

Correct = 1. Gather supplies for endotracheal intubation. Expected findings of alcohol toxicity include; Respiratory Depression, Hypotension, Cool Skin *Aspiration of emesis is a potential risk for a client. The nurse should implement measures to reduce the risk of aspiration of emesis for a client who has alcohol poisoning. Low-Fowler's position can increase the client's risk for aspiration.

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse client relationship, which of the following actions should the nurse take? 1. Inform the client that this admission is confidential. 2. Introduce the client to other clients in the day room. 3. Assist the client in facilitating behavioral change. 4. Determine coping strategies that the client has used in the past.

Correct = 1. Inform the client that this admission is confidential. According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take? 1. Move the client who has bipolar disorder to a private room. 2. Administer sleep medication to the client who has bipolar disorder. 3. Move the client who has severe depression to a private room. 4. Administer sleep medication to the client who has severe depression.

Correct = 1. Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room. *Clients who have severe depression are often at risk for self-harm and feel isolated. Therefore, the nurse should not move this client to a private room.

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply to the situation? 1. Nonmaleficence 2. Veracity 3. Justice 4. Autonomy

Correct = 1. Nonmaleficence It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit.

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? 1. Promote use of music to compete with the client's auditory hallucination 2. Inform the client that the auditory hallucinations are not real 3. Avoid asking the client if they are experiencing auditory hallucinations 4. Instruct the client on the use of voice recognition regarding the auditory hallucinations

Correct = 1. Promote the use of music to compete with the client's auditory hallucinations Competing reality based stimulating such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level *The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that others cannot hear anything to reinforce reality. The nurse should ask the client if they are hearing voices to evaluate whether these are command hallucinations, which can place the client or others at risk for harm. The nurse should assist the client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to stop, which gives the client a sense of control

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? 1. The client needs excessive external input to make everyday decisions. 2. The client demonstrates a dedication to their job that excludes time for leisure activities. 3. The client adheres to a rigid set of rules. 4. The client has difficulty starting new relationships unless they feel accepted.

Correct = 1. The client needs excessive external input to make everyday decisions. Clients who have dependent personality disorder need excessive input from others to make everyday decisions. *Obsessive Compulsive Personality Disorder = Demonstrate a dedication to work that excludes time for other activities, and adhere to a rigid set of rules. *Avoidant Personality = Unwilling to get involved socially unless they feel accepted

A nurse is preparing to administer diazepam 7.5mg IV Bolus to a client for alcohol withdrawal. Available is diazepam injection 5mg/1mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct = 1.5mL Follow these steps for the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) XmL = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) X mL = 1mL/5mg Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. XmL = 1mL/5mg x 7.5mg/1 Step 4: Solve for X.--> 7.5mg Divided by 5mg XmL = 1.5 Step 5: Round if necessary. Step 6: Determine whether the amount to administer makes sense. If there are 5 mg/mL and the prescription reads 7.5 mg, it makes sense to administer 1.5 mL. The nurse should administer diazepam 1.5 mL IV bolus.

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? 1. A client who has a fasting blood glucose level of 80 mg/dL 2. A client who has a sodium level of 128 mEq/L 3. A client who has a BUN of 18 mg/dL 4. A client who has a potassium level of 3.6 mEq/L

Correct = 2. A client who has a sodium level of 128 mEq/L A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.

A nurse is caring for a group of clients. Which of the following finding should the nurse report? 1. A client who is taking clozapine and has a WBC count of 7,500 2. A client who is taking lamotrigine and has developed a rash 3. A client who is taking valproate and has a platelet count of 150,000 4. A client who is taking lithium and has a lithium level of 1.2

Correct = 2. A client who is taking lamotrigine and has developed a rash Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life threatening adverse effect of the medication and report the finding immediately

A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours ago following a motor vehicle crash. The client's admission blood alcohol level was 325mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? 1. Somnolence 2. Blood pressure 154/96 mm Hg 3. Pinpoint pupils 4. Blood glucose 210 mg/dL

Correct = 2. Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, profuse sweating, dilated pupils, tremors, hypoglycemia, and a fever greater than 38.3° C (100.9° F). It will be important for the nurse to rule out infection in the client who has a fever.

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include? 1. Additional acute episodes of depression are unlikely following inpatient care. 2. Early identification of changes, such as decreased social involvement, is important. 3. Medication compliance will prevent further need for inpatient hospitalization. 4. It is helpful to regularly reinforce to the client that things will get better.

Correct = 2. Early identification of changes, such as decreased social involvement, is important. Decrease social involvement is a manifestation of depression, and early identification of findings can lead to early intervention

A nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take? 1. Place the client in mechanical restraints. 2. Ensure security personnel are available in the background to assist if the client's behavior escalates. 3. Ask the client, "Why are you so upset?" 4. Remain within arms length of the client in case they need to be quickly removed from the room.

Correct = 2. Ensure security personnel are available in the background to assist if the client's behavior escalates. The nurse should attempt to de-escalate the situation using less restrictive techniques, such as therapeutic communication, decreasing stimulation, or pharmacological measures. The client is exhibiting manifestations of anger and agitation that often precede a violent event. While the nurse should attempt to de-escalate the situation, safety measures should be in place. The nurse should verify that assistance is available if the client becomes violent. Security should be kept out of the client's line of sight until they are needed to avoid escalating the situation.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? 1. Provide teaching about the use of positive coping mechanisms. 2. Establish screening programs to identify at-risk clients. 3. Refer survivors of intimate partner abuse to a legal advocacy program. 4. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

Correct = 2. Establish screening programs to identify at-risk clients. This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs. *Primary Prevention: Provide teaching about the use of positive coping mechanisms. Positive coping mechanisms help clients and their partners cope with stress and help to prevent the incidences of partner violence in the community. *Tertiary Prevention = Takes place after partner violence has occurred. Refer survivors of intimate partner abuse to a legal advocacy program. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

A nurse in a community health center is working with a group of clients who have post traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? 1. Response prevention 2. Guided imagery 3. Aversion therapy 4. Light therapy

Correct = 2. Guided imagery Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder. *Response Prevention = Used in the treatment of Compulsive Behavior *Aversion Therapy = A negative feedback method used to treat Alcohol Use Disorder, Violent Behavior, and Self Mutilation *Light Therapy = Used in the treatment of Seasonal Affective Disorder

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? 1. Polyphagia 2. Hypertension 3. Decreased temperature 4. Depressed mood

Correct = 2. Hypertension Cocaine is a stimulant that increases blood pressure, decreases appetite, increases body temperatures, and causes feelings of exhilarations and increased energy.

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider? 1. Obsessive attention to detail 2. Inability to sleep 3. Reports of fatigue 4. Isolation from others

Correct = 2. Inability to sleep During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? 1. Behave in a friendly manner toward the client. 2. Set realistic limits on the client's behavior. 3. Show respect for the client's need for isolation. 4. Act as a role model for assertiveness.

Correct = 2. Set realistic limits on the client's behavior. Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish clear limits on specific aggressive and demanding behaviors. Clients who have antisocial personality disorder do not seek isolation. They show antagonistic behavior toward others and often have a history of criminal misconduct. Clients who have antisocial personality disorder do not lack assertiveness. They tend to act in an aggressive and exploitative manner. *Behave in a friendly manner toward the client --> Strategy should be used for clients who have Avoidant Personality Disorder *Show respect for the client's need for isolation --> Strategy should be used for clients who have Schizotypal Personality Disorder *Act as a role model for assertiveness --> Strategy should be used for clients who have Dependent or Histrionic Personality Disorders

A nurse is discussing a 12 steps program with a client who has alcohol use disorder and is in an acute facility undergoing detoxification. Which of the following information should the nurse include in the teaching? 1. The program will help the client accept responsibility for the disorder. 2. The client should obtain a sponsor before discharge for an increased chance of recovery. 3. The client will need to identify individuals who have contributed to the disorder. 4. The program will need a prescription from the client's provider prior to attendance.

Correct = 2. The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program. *The nurse should teach the client that they cannot blame others for contributing to their disorder. The program will have the client identify individuals that they have harmed because of the disorder. The nurse should teach the client that they are weak in regards to alcohol and therefore not responsible for the disorder, but they are responsible for their individual recovery.

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!". Which of the following responses should the nurse make? 1. "Why do you think you deserve this punishment?" 2. "Don't worry about being punished by God." 3. "Let's talk about what is upsetting you." 4. "You shouldn't say things that will upset you so much."

Correct = 3. "Let's talk about what is upsetting you." The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? 1. A client refuses electroconvulsive therapy after signing the consent form. 2. A client who was voluntarily admitted left the unit against medical advice. 3. A client was administered one-half of the prescribed dose of medication. 4. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.

Correct = 3. A client was administered one-half of the prescribed dose of medication. An incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form.

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? 1. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. 2. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. 3. A client who has borderline personality disorder threatened to harm their roommate. 4. An adolescent client who has anorexia nervosa has a BMI of 17.

Correct = 3. A client who has borderline personality disorder threatened to harm their roommate. Manifestations of borderline personality disorder include disturbed interpersonal relationships accompanied by threats and other-directed violence. While it is important for the nurse to maintain the client's confidentiality, on occasions when another individual's life might be in danger, the nurse is required by law to report it to authorities. *The nurse has the duty to maintain confidentiality regarding the client's conversations with the nurse. Since genital herpes simplex virus is not a condition that needs to be reported, the nurse is not obligated to report the infection. The nurse should encourage the client to contact the client's sexual partners to inform them of the need to obtain testing and treatment if necessary.

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? 1. Delusions 2. Neologisms 3. Anhedonia 4. Echopraxia

Correct = 3. Anhedonia Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? 1. Call the provider to obtain an immediate prescription for restraint. 2. Prepare to administer benzodiazepine IM. 3. Call for a team of staff members to help with the situation. 4. Check the client who was hit for injuries.

Correct = 3. Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A nurse in a provider's office is collecting a health history from the guardian of a school age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? 1. Reduced appetite 2. Fatigue 3. Dark urine 4. Sweating

Correct = 3. Dark urine The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death. Therefore, this is the nurse's priority finding.

A nurse in a community health center is teaching families of clients who have post traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? 1. Repeatedly talks about the traumatic incident 2. Sleeps excessively 3. Experiences feelings of isolation 4. Uses repetitive speech

Correct = 3. Experiences feelings of isolation The nurse should expect clients who have PTSD to feel estranged/detached from others, avoid discussing the traumatic event, have difficulty sleeping, hypervigilance, and verbal aggression

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? 1. Encourage the client to participate in group therapy. 2. Instruct the client to avoid napping during the day. 3. Offer the client high-calorie finger foods frequently. 4. Decrease the client's daily fiber intake.

Correct = 3. Offer the client high-calorie finger foods frequently. The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration. *The nurse should maintain a low-stimuli environment for a client who is experiencing mania. The nurse should dim the lights, decrease noise, and limit the number of people the client is around. The nurse should encourage the client to take frequent rest periods throughout the day. Clients experiencing mania are at risk of exhaustion that can be life threatening. The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients experiencing mania can experience dehydration and nutritional deficiencies from decreased intake, which can lead to constipation.

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? 1. Offer the client various choices for meal selection. 2. Assign different nursing personnel for each shift. 3. Permit the client to perform daily rituals to decrease anxiety. 4. Maintain an environment that has low lighting.

Correct = 3. Permit the client to perform daily rituals to decrease anxiety. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? 1. Encourage the parents to avoid discussing the death with their other children to protect their feelings. 2. Recommend each parent grieve in private to avoid hindering each other's healing. 3. Suggest forming a weekly support group for parents who have experienced the death of a child. 4. Advise the parents to begin counseling if they are still grieving in a few months.

Correct = 3. Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child.

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? 1. Weight gain 2. Tinnitus 3. Tachycardia 4. Increased salivation

Correct = 3. Tachycardia Tachycardia, Weigh Loss, and Dry Mouth are all adverse effects of methylphenidate.

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? 1. The client is married. 2. The client has recently been promoted at work. 3. The client has COPD. 4. The client was assigned male at birth.

Correct = 3. The client has COPD. The nurse should identify that clients who have a chronic medical illness, who are assigned female at birth, who are single, and the presence of a negative life event are at an increased risk for the development of depression.

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the follow statements indicates that the client is at risk for complicated grief? 1. "I wish I had been nicer and more generous with my wife before she died." 2. "I told my wife to go to the doctor, but she wouldn't listen to me." 3. "I think about my wife all the time when I go on outings with my family." 4. "I feel so empty without my wife that it's hard to get up every morning."

Correct = 4. "I feel so empty without my wife that it's hard to get up every morning." The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief. *Guilt, Anger, and Preoccupation with the Deceased are all expected findings of Grief

A nurse on an acute mental health facility is receiving a change of shift report for four clients. Which of the following clients should the nurse assess first? 1. A client who does not recognize familiar people 2. A client who cannot verbalize their needs 3. A client who is awake and disoriented at night 4. A client who is experiencing delusions of persecution

Correct = 4. A client who is experiencing delusions of persecution The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first.

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home? 1. Community mental health center 2. Mental health day program 3. Partial hospitalization program 4. Assertive community treatment

Correct = 4. Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? 1. Slow onset 2. Aphasia 3. Confabulation 4. Easily distracted

Correct = 4. Easily Distracted Extreme distractibility and acute onset is a hallmark manifestation of delirium. *Slow, Progressive Decline, Aphasia, and Confabulation are all manifestations of Dementia

A nurse in a mental health facility is caring for a client who requires the use of restraints. Which of the following actions should the nurse take when caring for the client? 1. Complete written documentation every 60 min. 2. Request a PRN prescription for restraints after the client has been reintegrated to the unit. 3. Renew prescription for restraints every 48 hr. 4. Ensure a staff member checks on the client every 15 min.

Correct = 4. Ensure a staff member checks on the client every 15 min. When caring for a client who is in restraints, the nurse should complete written documentation per facility policy, usually every 15 min. The nurse should assess the client's needs for hydration and elimination and monitor the circulation in the extremities every 15 min and document these interventions. *Orders for restrains cannot be written on an "as needed" (PRN) basis. *A renewal prescription for restraints is completed every 24 hr.

A school nurse is assessing a school aged child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD) 1. Clinging behaviors directed toward a teacher 2. Increased time spent sleeping 3. Intense focus on school work 4. Lack of interest in an upcoming holiday

Correct = 4. Lack of interest in an upcoming holiday The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events (e.g., Holidays) *PTSD manifestations seen in children include detachment or estrangement from others, difficulty sleeping/distressing dreams, difficulty concentrating on tasks

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? 1. Fear of abandonment 2. Motor and verbal tics 3. Hostile behavior 4. Language delay

Correct = 4. Language Delay The nurse should identify that language delays are a manifestation of autism spectrum disorder. *Fear of Abandonment = Manifestation of Separation Anxiety Disorder *Motor and Verbal Tics = Manifestations of Tourette's Syndrome *Hostile Behavior = Manifestation of Oppositional Defiant Disorder

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? 1. Panic 2. Moderate 3. Severe 4. Mild

Correct = 4. Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information. *Moderate, Severe, and Panic levels of anxiety will interfere with the client's ability to concentrate and process information

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? 1. Administer phenytoin 30 min prior to the procedure. 2. Inform the client they may have a headache following the procedure. 3. Place the client in four-point restraints prior to the procedure. 4. Monitor the client's cardiac rhythm during the procedure.

Correct = 4. Monitor the client's cardiac rhythm during the procedure. The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram. *The purpose of ECT is to induce a short seizure by stimulating the brain with an electrical current *The client will receive anesthetic and paralytic medications immediately prior to the procedure to prevent severe muscle contractions induced by the seizure *Temporary Disorientation, Confusion, Possible Memory Deficits are all expected adverse effects of ECT

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? 1. Encourage expression of feelings. 2. Support the child's attendance at an assertiveness training group. 3. Assist the child to perform relaxation breathing. 4. Reduce environmental stimuli.

Correct = 4. Reduce environmental stimuli. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? 1. Allowing a client to choose which unit activities to attend 2. Attempting alternative therapies instead of restraints for a client who is combative 3. Providing a client with accurate information about their prognosis 4. Spending adequate time with a client who is verbally abusive

Correct = 4. Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care.