Hesi Mental health

Which response from the client indicates that the haloperidol has been effective?

Experiences fewer hallucinations. Rationale: The client should experience fewer hallucinations if the medication has been effective.

When the nurse prepares the client for ECT, what should be expected?

Preparation is similar to a brief surgical procedure. Rationale: Preparation for ECT is similar to a surgical procedure. For example, the client must remain NPO for 6 to 8 hours prior to treatment with the exception of receiving cardiac medications or antihypertensive agents. Prostheses should be removed, and the client should void immediately before receiving ECT.

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond?

State how he must be concerned and assure him he will be safe there. Rationale: The nurse should respond to the client's underlying feelings and not make assumptions about his delusions.

Which question should the nurse ask the client in order to determine whether the client is able to return to a precrisis level of functioning?

"Do you have a support system and people who can help you?" Rationale: The nurse must determine if the client has an adequate support system.

A simple tool the nurse can use to screen for alcoholism is the CAGE questionnaire. CAGE is an acronym that represents the four questions it contains. What is the first question that the nurse should ask?

"Have you ever thought that you should cut down on your drinking?" Rationale: This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior. When sober, an alcoholic may make a pledge to reduce consumption.

Routine admission prescrptions include regular diet, nutrition consultation, vital signs every 4 hours, CBC with differential, urinalysis, and urine drug screen. The healthcare provider also prescribes acetaminophen 325 mg by mouth (PO) every 6 hours as needed (PRN) for pain, fever, or headache. Which routine admission prescriptions should the nurse question?

Acetaminophen as needed. Rationale: The client is suspected of having liver problems due to alcohol. Acetaminophen can be toxic to the liver, especially in combination with alcohol. The nurse should question this prescription as it is contraindicated for the client.

After the content of the voices are assessed, which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

Ask the client how the voices make them feel. Rationale: It may be helpful to know how the voices make the client feel. It can provide understanding to the client's actions and reactions so they can be addressed in a therapeutic manner. Instruct the client to utilize distractions to deal with hallucinations. Rationale: Once the hallucinations have been revealed and evaluated, it is important to disconnect the hallucinations from reality. Distractions can be a therapeutic.

When the client looks around the room and mumbles to himself, how should the nurse respond?

Ask the client if they are hearing voices. Rationale: The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices.

Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him?

Delusions. Rationale: A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.

The nurse understands that the purpose of the urine drug screen is to assess the client for what important information?

Detection of substances that may have caused the client's delusions and/or hallucinations. Rationale: A urine drug screen is routinely ordered to determine the presence of any substances that may have altered a client's mental status. Blood and urine are the body fluids most often tested for drug content, although methods of analyzing saliva, hair, breath, and sweat have been developed.

Which priority nursing problem should be addressed within 72 hours of admission? (Select all that apply.)

Risk for injury. Rationale: Risk for injury related to the client's thoughts of wanting to jump off a bridge is a priority nursing problem and the rationale for admission to the crisis unit. Altered nutrition. Rationale: A client with alcohol dependency drinks alcohol instead of eating nourishing food, causing malabsorption of essential vitamins. Deficiency and malabsorption of vitamin B can cause Wernicke's disease, a severe problem with decreased cognitive functioning. Risk for withdrawal. Rationale: Alcohol withdrawal can occur as early as 4 to 6 hours after the client's last drink.

A mental health technician arrives to help the client take a shower. The technician gathers towels and shower items, then helps the client to the shower. When entering the shower, the client slips and falls to the floor. The technician reports the incident to the nurse. The nurse assesses the client who denies suffering any injuries. The nurse documents the assessment, which includes a full set of vital signs, and then notifies the healthcare provider (HCP). The nurse knows an adverse event report must be completed. Who should the nurse ask to complete the adverse event report?

The technician helping at the time of the accident needs to complete the report. Rationale: The nurse should ask the technician to complete the report because the technician witnessed the client's fall.

The nurse asks the client to sign the consent for treatment. If the client refuses treatment, which behaviors justify short-term involuntary treatment? (Select all that apply. One, some, or all options may be correct.)

Unable to meet basic self-care needs. Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-care needs in such a way that he or she is a danger to self. States she has a plan to harm herself. Rationale: Short-term involuntary care may be initiated to protect the client if she has a plan to harm herself. It can also be initiated if she presents an intentional danger to others.

Which assessment is most important for safe alcohol detoxification?

Vital signs at least every 4 hours. Rationale: Vital signs are an objective measure of alcohol withdrawal, especially when the diastolic blood pressure, pulse, and temperature are near or above 100.

Since the client is eating 50% of her meals, which nursing intervention should be included on the treatment plan?

Weigh weekly and document. Rationale: The most objective assessment related to the client's intake is frequent weighing to document any changes in weight that should be monitored more closely.

When should the nurse begin assessing for withdrawal?

Within 8 to 12 hours of the client's last drink. Rationale: Early alcohol withdrawal can begin as early as 4 to 6 hours after substance use is stopped.

Interventions for a client experiecing hallucinations upone admission should occur in a sequence. Which interventions are most important for the nurse to include in the client's initial plan of care? (Select all that apply. One, some, or all options may be correct.)

Acknowledge that it appears the client is hearing voices. Rationale: The initial approach is to acknowledge the voices. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Ask the client to verbalize what the voices are saying. Rationale: Once the voices are acknowledged, the nurse needs to know what the voices are saying. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Assess the content of the hallucinations message. Rationale: The voices may be telling the client to harm themself or others. Immediate interventions will need to be put in place to keep the client and others safe.

As the nurse initially communicates with the client, which communication technique is important?

Acknowledge the client's courage in seeking help, then offer to sit quietly with the client. Rationale: Offering nonjudgmental acceptance and companionship will help develop trust. Acknowledging the step the client took in seeking help may restore the client's sense of control over her situation.

Eight hours after admission, a new nurse is assigned to care for the client. After receiving report, the nurse reviews the recent information in the chart. Vital Signs Blood pressure 146/98 mmHg Heart rate 100 beats/min Respirations 22 breaths/min Temperature 99.8° F (37.7° C) Laboratory Data AST: 80 U/L (1.34 µkat/L) ALT: 96 U/L (1.60 µkat/L) Sodium: 145 mEq/L (145 mmol/L) Potassium: 3.6 mEq/L (3.6 mmol/L) Prescriptions 1. Perform withdrawal assessment every 4 hours. 2. Lorazepam 2 mg PO every 6 hours prn per alcohol withdrawal protocol. 3. Continue suicide precautions. The nurse performs the withdrawal assessment and observes moderate tremors. The client reports nausea. Which interventions should the nurse implement? (Select all that apply.)

Administer lorazepam 2 mg PO. Rationale: The client has compromised liver function; therefore, a short-acting benzodiazepine such as lorazepam is best to give for withdrawal because it does not have active metabolites that can affect a diseased liver. Lorazepam is often given if a client has known liver disease or decreased liver function. Reassess vital signs in 2 hours. Rationale: The nurse can reassess the vital signs to monitor for changes. Provide an antiemetic. Rationale: The client reports feeling nauseous, so administering an antiemetic is advised.

The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention is most important for the nurse to include in the client's plan of care?

Begin a sequence of interventions to address the client's hallucinations. Rationale: Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter.

The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content?

Content includes the clients' words, and group process is how the clients communicate. Rationale: Group content includes what the group members say, and group process refers to how they communicate their thoughts and feelings.

The nurse completes a physical assessment. When asked what brought her to the hospital, the client replies that things just aren't right and begins to cry. After further conversation, the client describes her mood as very sad now. She rarely goes out or invites friends to visit. She admits that she feels like strangers are saying bad things about her. Sometimes she hears a man's voice that is a little bit scary. What is the priority focused nursing assessment?

Determine how long the client has been hearing the voice and what it is saying. Rationale: Determining if voices are being heard and the type of voices are priority. The nurse must assess the content of the auditory hallucinations for the presence of command hallucinations. Command hallucinations may be telling the client to harm herself or others.

Which medication should the nurse give to immediately relieve the muscle spasms in the client's neck and jaw?

Diphenhydramine IM. Rationale: The client is experiencing a dystonic reaction, so the nurse should provide relief with diphenhydramine IM or benztropine IM.

After 3 days in the crisis stabilization unit, the client exhibits no further withdrawal symptoms. The nurse collaborates with the social worker and the HCP to determine discharge plans. The client wants to return to work as soon as possible. The client describes work as being a trigger for drinking and asks the nurse what can be done to prevent a relapse. Which response by the nurse is accurate?

Disulfiram inhibits absorption of alcohol. Rationale: Disulfiram inhibits the absorption of alcohol and raises the level of acetaldehyde, causing a severe reaction when alcohol is ingested.

What neurotransmitter is targeted by haloperidol?

Dopamine. Rationale: Traditional antipsychotics block excessive dopamine, an excitatory neurotransmitter, so that symptoms related to psychosis are reduced.

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions?

Encourage the client to verbalize the meaning of the delusions. Rationale: The underlying theme of the delusions can be used to address the client's emotional state. Monitoring the affect of the delusions can help identify situations where the client may be inclined to harm themselves or others.

The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication?

Explain that this pill is to help prevent the muscle spasms in neck and jaw. Rationale: The addition of benztropine will reduce the likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as haloperidol.

The nurse enters the client's room to assess readiness for teaching related to local 12-step programs and observes that the unlicensed assistive personnel (UAP) is already providing information about local programs. Which action should the nurse take?

Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse. Rationale: Initial client teaching requires the expertise of the nurse.

The client is placed on constant observation for safety precautions, so the nurse must assign a staff member to remain with her at all times. Which staff member is best to assign to the client?

Female unlicensed assistive personnel. Rationale: An unlicensed staff member can assume responsibility for the client's safety and maintain documentation. A female staff member is less threatening than a male staff member when the client desires as much privacy as possible.

What action should the nurse take next?

Further assess the client's drinking behaviors. Rationale: The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore, further assessment is needed to make a diagnosis of alcoholism.

Group activities, such as drawing, exercising to music, baking, community trips, and arts & crafts are offered on the unit. In the afternoon, the client decides to join the group that has chosen drawing as their activity. What is a goal of being in this activity group?

Gain self-acceptance and express feelings. Rationale: An activity group promotes self-acceptance, expression of feelings, and a focus on group goals rather than individual issues.

The nurse should be aware of common side effects of SSRI antidepressants such as fluoxetine. Which side effect should be communicated to the client that commonly occur in clients who are taking SSRI antidepressants?

Gastrointestinal disturbances. Rationale: GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual dysfunction, are common with SSRIs. SSRIs do not have significant anticholinergic, cardiovascular, or sedative side effects.

Which assessment data are the best indicators of the potential for violence? (Select all that apply. One, some, or all options may be correct.)

Gender and age. Rationale: Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. Past suicide attempts. Rationale: Past suicide attempts are indicators of violence toward self. History of violence. Rationale: The best single predictor of violence is a past history of violence. Medication noncompliance. Rationale: Clients with active psychotic symptoms are at increased risk for violence (symptom exacerbation), especially if they are medication noncompliant.

When the client receives fluoxetine, the nurse must explain the purpose and when to expect therapeutic effectiveness. What should the nurse tell the client regarding when she will begin to feel less depressed?

Generally within 1 to 4 weeks. Rationale: In general, it takes 2 to 4 weeks for antidepressant effects to begin. However, it depends on the individual, and some clients may feel effects start as soon as 1 week or as late as 4 weeks. It is suggested that depression occurs when a depletion of neurotransmitters in the synapse cause the transmitter receptors to increase. As the antidepressants make more transmitters available, it takes the receptors several weeks to return their numbers back to normal and allow normal synaptic activity.

The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing intervention best promotes effective communication?

Have the client repeat what he thinks the voices are saying. Rationale: The nurse should first ask what the voices are saying in order to assess for command hallucinations.

What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?

Headache and palpitations. Rationale: Explosive headache, palpitations, sudden elevation of blood pressure, chest pain, nausea, and vomiting are some of the symptoms of a hypertensive crisis related to tyramine consumption.

The nurse must teach the client about possible adverse effects from the ECT treatments. Which information should be included in the teaching plan?

Headache, nausea, and muscle aches may occur after the treatment. Rationale: Headache, nausea, and muscle aches are common side effects. Confusion and disorientation are short-term.

The client is assessed by the nurse, a social worker, and the healthcare provider (HCP). Based on their assessments, hospitalization is recommended for psychotic depression. Which behavior is inconsistent with depression?

Hearing a man's voice. Rationale: Auditory hallucinations are inconsistent with depression and are more likely to occur with psychoses. However, clients may experience a psychotic depression in which there is evidence of psychosis.

When the client awakens in the morning, she sits for periods of time at the edge of her bed. She does not initiate combing her hair, getting dressed, or going to breakfast. Which intervention should the nurse implement?

Help the client with daily activities. Rationale: When a client is very depressed, it is necessary to assist with daily activities because the client has decreased energy. Physical care is more important with severe depression.

The nurse is reviewing the client's admission lab work on the third day of hospitalization. Admission labs include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine drug screen, and VDRL (RPR) which tests for venereal disease. A thyroid profile is important for several reasons. What role do thyroid levels play in depression?

Hypothyroidism can lead to feeling sluggish and depressed. Rationale: Thyroid levels can help detect hypothyroidism, which can lead to depression.

While the nurse explains the potential consequences of drinking alcohol while taking disulfiram, the nurse also tells the client about household products containing alcohol that should be avoided, including cough medicine and aftershave lotion. Which products are acceptable for the client to use? (Select all that apply.)

Ibuprofen. Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication used to treat fever and mild to severe pain. It does not contain alcohol and is safe for the client to use. Petroleum jelly. Rationale: Petroleum jelly does not contain alcohol, so it is safe for the client to use.

What is the major action of SSRI antidepressants?

Increase availability of serotonin. Rationale: The major action of SSRIs is to selectively inhibit the reuptake of serotonin and increase the availability of serotonin.

Which lab results indicate to the nurse the client likely has liver disease?

Increased aspartate aminotransferase (AST). Rationale: Liver disease can cause a change in tissues of the liver and result in an elevation of AST. The amount of AST in the blood is directly related to the number of damaged cells.

What mechanism of action accounts for symptoms of alcohol withdrawal delirium?

Increased dopamine. Rationale: Alcohol intake represses gamma-aminobutyric acid (GABA), which inhibits dopamine. When alcohol is eliminated, dopamine rebounds above the normal level, resulting in excitation and alterations in thought, perception, and orientation.

Which assessment finding warrants immediate intervention by the nurse?

Involuntary muscle contractions. Rationale: Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, particularly of the face, tongue, neck, and jaw which is a serious side effect of halcinonide.

The nurse understands that a VDRL is routinely done on admission for which reason?

It is a screening test for syphilis. Rationale: A VDRL (RPR) is a serum screening test for syphilis, which can be undetected and dormant and can cause cognitive impairment in later stages. If the screening serum test is positive, a more specific test is required to make the diagnosis of syphilis.

Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving?

Losing 10 pounds in 2 weeks. Rationale: The criteria for commitment includes danger to self and/or others, unable to provide for own basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss demonstrates the client's inability to provide for his own basic needs by not maintaining adequate nutrition.

What are the advantages for prescribing the atypical antipsychotic, olanzapine? (Select all that apply. One, some, or all options may be correct.)

Lower incidence of extrapyramidal symptoms (EPSEs). Rationale: Olanzapine has fewer incidences of extrapyramidal side effects (EPSEs) than other antipsychotic medications. Rapid onset. Rationale: Olanzapine has a rapid onset. Acute and maintenance therapy. Rationale: Olanzapine injection is effective in the treatment of acutely agitated psychotic clients and there is sustained efficacy when the client is switched to oral maintenance treatment.

The client signs the treatment form and is admitted to the mental health unit. During the first days of hospitalization, she begins antidepressant therapy with fluoxetine 10 mg. In what classification of drugs is the antidepressant fluoxetine?

Selective serotonin reuptake inhibitor (SSRI). Rationale: Fluoxetine is an SSRI antidepressant.

After several days of taking an MAO Inhibitor, the client refuses to continue taking the medication, and the medication is discontinued. Which specific nursing consideration is most important?

Maintain a low-tyramine or tyramine-free diet for 10 to 14 days. Rationale: The client should minimize or avoid substances with tyramine for 10 to 14 days after discontinuation of the medication due to the medication still in the client's system.

The nurse plans to give the client a list of safe and unsafe foods that contain tyramine. Unsafe foods have high tyramine content, and safe foods have little or no tyramine. Which food would be considered safe?

Most fruits. Rationale: Most fruits are safe, except figs, especially if overripe, and bananas in large amounts. Some foods with tyramine can be used with caution.

As the client is leaving the unit, the caseworker remembers that some of the client's medication bottles were brought to the hospital and the caseworker wants to return them to the client. Which nursing action is appropriate for this request?

Obtain a prescription from the HCP to return medications. Rationale: The HCP must write a prescription for the client to receive medications. Medications were changed while hospitalized and required prescriptions should accompany the client upon discharge. All other medication should be properly disposed of as prescribed.

Which nursing intervention is most important to implement before disulfiram therapy?

Obtain the client's written consent to comply with facility protocol. Rationale: Informed consent must be obtained to receive disulfiram therapy, or documentation can be noted in the chart that education was given about potential serious complications that can occur if client does not abstain from drinking.

Which goal is most important for alcohol detoxification?

Physiological stabilization. Rationale: The acute management goals of alcohol detoxification begin with stabilizing the client physically and maintaining normal vital signs.

Since the client has decreased energy, which additional intervention should the nurse implement?

Plan a scheduled rest period. Rationale: It is best to plan rest periods according to the client's energy level because some clients feel best in the morning and others feel best in the evening.

Which lab values from the urinalysis can the nurse expect to be related to the client's 10-pound weight loss in the past 2 weeks? (Select all that apply. One, some, or all options may be correct.)

Positive ketones. Rationale: Ketones in the urine can suggest malnutrition, fasting, or starvation. Increased urine specific gravity. Rationale: Increased urine specific gravity is associated with dehydration which could be contributing to the client's weight loss.

What is the therapeutic action of benzodiazepines?

Potentiate the effects of GABA. Rationale: Benzodiazepines potentiate the effects of GABA, which has a calming effect.

While the client is on constant observation, the nurse must assure that safety is maintained in the milieu. One afternoon, the nurse notices that a visitor brings some cans of the client's favorite soft drink. After ensuring the client is not on caffeine or sugar restrictions, what should the nurse do?

Pour the soft drink into a paper cup. Rationale: The nurse should pour the drink in a paper cup, because the client could use the can to hurt herself.

What is it most important intervention for the nurse to perform before discharging the client?

Re-evaluate thoughts of harm to self or others. Rationale: It is very important to reassess that the client is free of suicidal and/or homicidal ideation so that the nurse can document this in the discharge notes.

What is the most important benefit the client can receive from his attendance at the community meeting?

Reality orientation. Rationale: Meetings that are designed to introduce clients to one another, plan activities for the day, and address client concerns and questions help ground the psychotic client in the present and reality.

What is the rationale for giving thiamine (B1) and a multivitamin?

Reduce the risk of Wernicke disease. Rationale: Vitamin B deficiency is common in clients diagnosed with alcoholism. The small intestine is a major site of alcohol absorption, which interferes with adequate thiamine and all B vitamin absorption. Vitamin B deficiency can cause Wernicke disease.

One morning, the nurse is doing unit rounds and finds the client sitting at the edge of her bed with a sheet around her neck. After removing the sheet, what is the next nursing action?

Remain with the client. Rationale: The nurse should begin constant observation immediately for safety precautions because the client is at risk for self-harm. The other interventions are important, but it is most important for a staff member to remain with the client.

While teaching the client about the anticholinergic side effects related to benztrophine, which intervention is most important for the nurse to include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

Report urinary retention or feeling that the bladder does not empty. Rationale: Serious side effects include urinary retention, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs. Dry mouth and constipation are less serious anticholinergic effects. Relay any feeling of heart palpations. Rationale: Tachycardia, palpitations, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs are all serious anticholinergic side effects. Dry mouth, constipation, and drowsiness are less serious anticholinergic effects.

Which is the most important consideration for discharge planning?

Resources available to the client after discharge. Rationale: The most important consideration is the availability of resources to the client after discharge. These resources can include counseling with significant others, group therapy, and self-help programs like Alcoholics Anonymous.

The client also begins an atypical antipsychotic, risperidone, because she reports hearing a "scary voice" upon admission. Although the client remains very withdrawn and noncommunicative, the nurse must explain the purpose of risperidone. Which explanation is best?

Risperidone will help the think more clearly. Rationale: Antipsychotic medications target symptoms related to disorders of thinking such as psychosis and behaviors associated with agitation and disorganization or speech and behavior.

Because the client has hallucinations and delusions, the nurse develops an initial plan of care related to psychosis. Which nursing diagnosis is best to include in the initial care plan?

Sensory-perceptual alteration related to withdrawal into self. Rationale: The priority nursing diagnosis is related to the client's hallucinations, which impact his functioning and social interaction.

What are the ramifications of drinking alcohol while taking disulfiram? (Select all that apply.)

Severe headache. Rationale: A severe headache is one of the unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Nausea and vomiting. Rationale: Nausea and vomiting are unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Chest pain. Rationale: Chest pain is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Hypotension. Rationale: Hypotension is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor.

The client becomes very agitated and angry, and he talks loudly to himself as he waits to be seen by the healthcare provider (HCP). Which medications should the nurse anticipate giving the client after securing a prescription from the healthcare provider? (Select all that apply. One, some, or all options may be correct.)

Short-acting anxiolytic (benzodiazepines). Rationale: Antianxiety medications (benzodiazepines, lorazepam clonazepam, or diazepam) are most effective for anxiety-related symptoms to produce calming and sedation. When used in conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines, especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating acute agitation of a client. Antipsychotic medication. Rationale: Antipsychotic medications are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness.

According to the nursing progress notes, the client demonstrates decreased social interaction, she rarely talks, she needs assistance to her room and appears confused. The client only slept 30 minutes in the past 24 hours, and the daily graphics indicate that she has slept an average of 2 hours in the past week. She is eating 50% of her meals. According to this data, what is the priority nursing problem?

Sleep disturbance. Rationale: Considering Maslow's hierarchy, physiologic needs should be addressed first, so this is the priority problem because the client is receiving inadequate sleep. Eating 50% of her meals is acceptable, provided that the client is not losing weight.

The nurse stays with the client until another staff member arrives and safety precautions are initiated. A staff member must keep the client within eye sight at all times and document her activity every 15 minutes. When the client wants to change clothes and get ready for sleep at night, what should the staff do?

Stay with the client while she gets ready. Rationale: This approach respects the client's privacy and also ensures she stays safe.

As part of the admission process, the nurse orients the client to the program and to his room. What is the most important part of this admission process?

Take away the client's cigarettes and lighter. Rationale: Safety for the client and the unit environment is the highest priority, so the staff should keep any potentially dangerous objects away from the client.

On the fifth hospital day, the client reports feeling dizzy as he stands to leave the morning group activity. Which action should the nurse implement first?

Take the client's blood pressure while he is sitting and standing. Rationale: Since the client is feeling dizzy, a blood pressure reading should be taken while he is both sitting and standing to determine if a positional change, referred to as orthostatic hypotension, is associated with a change in the blood pressure readings.

When the client awakens from the treatment, the nurse should be prepared to perform which nursing action?

Take vital signs and assess orientation. Rationale: The nurse should monitor orientation and vital signs until they return to an acceptable level or for a specified time according to hospital protocol.

The nurse reports the elevated blood pressure to the HCP, and the client is prescribed hydrochlorothiazide 25 mg by mouth (PO) daily. The nurse collaborates with the dietitians about the client's meal plan. Which dietary instruction should the nurse provide the client taking hydrochlorothiazide?

Teach the DASH eating plan. Rationale: Dietary Approaches to Stop Hypertension (DASH) eating plan, which includes reduced fat intake and increased intake of fruits and vegetables.

Which items can the nurse allow the client to keep in the room? (Select all that apply.)

Tennis shoes without laces. Rationale: Tennis shoes without laces do not typically pose a threat. Electronic book reader. Rationale: The client may keep an electronic book reader, but it cannot connect to the internet. The client must keep the battery's charging cord at the nurse's desk and the staff will charge the battery when needed. A personal photo. Rationale: Personal photos do not pose a threat and may help the client feel more comfortable in the environment.

After several days of constant observation, the nurse reassesses the need to maintain safety precautions. What is the best predictor of client safety?

The client agrees to talk with staff if she has thoughts of self-harm. Rationale: If the client agrees to talk with staff if thoughts of self-harm occur, constant observation for safety can be changed. Risk for self-harm should continue to be assessed every shift.

One morning, the nurse takes the client's vital signs and notes her blood pressure is 141/108 mmHg. The progress notes indicate this is the third incidence of a high blood pressure. Which consideration by the nurse is accurate?

The client's diet, which consists of primarily high sodium foods, could be contributing to her high blood pressure. Rationale: A high sodium diet can lead to hypertension and fluid retention.

Which behaviors of the client's partner exhibit codependency toward the client? (Select all that apply.)

The client's partner states that moving out of their home caused the client to start drinking heavily. Rationale: Finding excuses for alcohol abuse is considered codependent behavior. The client's partner removed hidden alcohol from the home and is now moving back to keep a close eye on the client. Rationale: The client's partner feels responsible for the client. Searching for and removing alcohol from the home is further evidence of codependent behavior. The client's partner paid all of the bills for the next two months so that the client won't have to worry about finances when discharged. Rationale: This shows that the client's partner feels a need to control the finances and assume responsibility for the client's duties.

If it is determined the client is dependent on alcohol, which information should the nurse obtain in order to predict the onset of withdrawal symptoms?

The last time the client consumed an alcoholic beverage. Rationale: This can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 6 to 8 hours after alcohol use.

The nurse completes the assessment and reports the findings to the healthcare provider (HCP). The HCP talks with the client who is admitted to the crisis unit with an admitting diagnosis of alcohol dependency and depression with suicidal ideation. Which data supports the need for admission to the hospital?

Thoughts of wanting to jump off a bridge. Rationale: The client is at risk for self-harm, which is a priority problem that requires hospitalization.

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication?

To determine if other medical issues are present. Rationale: A CBC can provide helpful information on the client's health status. It is important to determine if there are other issues that could be causing some of the symptoms, and whether the client is healthy enough to take the medication. Some antypsychotic medications can cause neutropenia. If the client has other medical issues, considerations will need to be discussed regarding what medications should be prescribed.

After 9 days of hospitalization, the client demonstrates fewer hallucinations, and his thoughts are not influenced by delusions. The client explains that several months before admission, he and his HCP decided that he could stop taking his psychotropic medications. He states that he does not know what happened and stated that he thought that he was handling everything just fine. The client's discharge is planned within several days. Medication prescriptions for discharge include olanzapine 5 mg PO daily BID. The nurse plans to educate the client about side effects that do not go away. What are important reasons for this teaching? (Select all that apply. One, some, or all options may be correct.)

To encourage the client to continue compliance with medications. Rationale: Education about side effects is important so that medication compliance can be enhanced. To monitor for early tardive dyskinesia, which can be reversible. Rationale: It is very important to teach the client to report uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia and suggest modifications in the client's medication regimen. Tardive dyskinesia, although rare with olanzapine, can be reversed, by reducing the medication dose, if it is assessed in a timely manner. To reinforce education done throughout the hospitalization. Rationale: Educating the client about medications at discharge will reinforce the client's knowledge To tell the cliet to discuss symptoms with his nurse. Rationale: It is very important to reinforce the client's medication compliance by recommending that the client discuss any uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia.

Which should the nurse anticipate if the client experiences symptoms of early withdrawal from alcohol?

Tremors, nausea, and vomiting. Rationale: In addition to tremors, nausea, and vomiting, other symptoms of early withdrawal include elevated vital signs, diaphoresis, insomnia, combativeness, agitation, and decreased concentration.

The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant therapy. What is the rationale?

Tricyclics have more dangerous side effects. Rationale: SSRIs are more widely prescribed than tricyclics because they have fewer side effects, and tricyclics can be lethal in an overdose because they are cardiotoxic.