focused review

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Hypertension Rationale: Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism.

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Set realistic limits on the client's behavior Rationale: 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.

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

Substance use disorder Rationale: The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash. Rationale: The client experiences a situational crisis when an unexpected event occurs.

A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations?

Feelings of hopelessness Anhedonia Flat facial expression Rationale: Feelings of hopelessness is correct. The nurse should document feelings of hopelessness as a clinical manifestation of major depressive disorder. Anhedonia is correct. The nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorder. Flat facial expression is correct. The nurse should document a flat facial expression as a clinical manifestation of major depressive disorder.

a nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Hand tremors Rationale: Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication.

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine?

St. john's Wort Rationale: St. John's wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?

Talk with the client about activities they enjoyed with their partner. Rationale: Talking about positive experiences can help distract the client from their disorientation.

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?

The client is interested in what the nurse is saying. Rationale: The client's posture and eye contact demonstrates an interest in the interview and what the nurse is saying.

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?

The client needs excessive external input to make everyday decisions. Rationale: Clients who have dependent personality disorder need excessive input from others to make everyday decisions.

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?

A client who has a sodium level of 128 mEq/L Rationale: 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 findings is the nurse required to report?

A client who has borderline personality disorder threatened to harm their roommate. Rationale: 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.

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

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

A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate?

Aggression toward animals. Rationale: The nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder.

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer. Rationale: Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?

"I am able to go to work every day, so I don't have a problem." Rationale: By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder.

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning." Rationale: The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief.

A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication?

"I should eat a regular diet with normal amounts of salt and fluids." Rationale: The nurse should identify that this statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity.

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?

"It is easier to talk about my feelings now." Rationale: When clients express their feelings, this indicates a positive treatment outcome.

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?

Anhedonia Rationale: 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 is planning care or an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?

Arrange one-to-one observation of the client. Rationale: The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

Ask the client what the voices are saying Rationale: It is important for the nurse to ask the client directly about the hallucinations to determine if the client or others are at risk for injury.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?

Diazepam 5 mg IV bolus Rationale: The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations.

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?

Do not administer the lorazepam Rationale: Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment. Therefore, the nurse should hold the medication and document the client's refusal.

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Emotional lability Rationale: 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.

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?

Encourage frequent rest periods throughout the day. Rationale: A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake Rationale: The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?

Inappropriate dress Rationale: Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?

Instruct the client to avoid driving during initial therapy. Rationale: The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?

Interview the client in a private setting. Rationale: The nurse should interview clients in a private place when asking questions regarding client health.

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?

Orthostatic hypotension Rationale: Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.

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 plpan?

Promote the use of music to compete with the client's auditory hallucinations. Rationale: Competing reality-based stimulation 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.

A nurse us planning care for a newly admitted client who has bipolar and is experiencing mania. Which of the following is the priority action by the nurse?

Provide frequent high-calorie snacks Rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?

Refrains from manipulating others to earn dining room privileges Rationale: The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?

Remove unnecessary equipment from the child's surroundings. Rationale: The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM?

Shuffling gait Rationale: Benztropine is used to treat parkinsonism manifestations, such as shuffling gait.

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7% Rationale: The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider.

a nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

a client was administered one-half of the prescribed dose of medication Rationale: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 in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and a temperature of 39 9 C (103.8 F). Which of the following actions should the nurse take first?

determine patient's prescribed medication regimen Rationale: The first action the nurse should take when using the nursing process is to assess the client. By determining the client's prescribed medications, the nurse can determine the cause of the hypertension, such as the client taking an MAOI to treat depression. These medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine.

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?

frequently misplaces objects Rationale: According to evidence-based practice, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur.

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?

"In the event a client threatens harm to others, medications can be administered without consent." Rationale: The charge nurse should inform the participants that their primary commitment is to the client and their priority is always to advocate for and protect their health and safety. During an emergency situation, if the client is threatening harm to self or others, medications can be administered without the client's consent and without a court order.

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

"It is not uncommon to feel angry toward yourself or others." Rationale: Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make?

"Succinylcholine is given to reduce muscle movements during therapy." Rationale: Succinylcholine is a muscle-paralyzing agent that will decrease muscle movement during the procedure so the client is less likely to be injured.

a nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

"You might experience difficulties with sexual functioning while taking this medication." Rationale: Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs.

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take?

Ask the family member if they have any thoughts or questions about the treatment plan. Rationale: This action involves the family member and allows them a venue to communicate about the client's medication treatment plan.

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

Assess the client for evidence of a perceptual disturbance. Rationale: The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions.

A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?

Attending a relapse prevention group several times each week. Rationale: The nurse should identify that the most effective strategy for relapse prevention is a 12-step program, such as Alcoholics Anonymous.

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?

Attention to body language Rationale: Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.

A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching?

Avoid looking directly at the light during treatment. Rationale: Light therapy, or phototherapy, can cause sensitivity to light. To minimize this effect, the client should avoid looking directly at the light.

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?

If you do my homework for me, I won't bother you for the rest of the day Rationale: 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 delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?

Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. Rationale: A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound.

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?

Clang association Rationale:The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have a similar sound.

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?

Dark urine Rataionale: 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 the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation. Rationale: The nurse should gather supplies for endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Report the occurrence to the charge nurse. Rationale:It is the charge nurse and the nurse manager's responsibility to confront the staff member about the derogatory comments made to the client.

A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver?

Respite Care Rationale: Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

The client reports an inability to breath easily. Rationale: Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations. Rationale: The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

The client will refrain from self-mutilation. Greatest risk to the client is injury to self and others Rationale: The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the client to refrain from self-mutilation.