NURS 3554. ATI Prep (Part 1)

A nurse working in the emergency department is caring for a client following an overdose of pentobarbital sodium. For which of the following findings should the nurse assess the client? A. Cerebrovascular accident B. Dysrhythmias C. Liver failure D. Respiratory depression

D. Respiratory depression Pentobarbital is a barbiturate that is used for seizure disorders, induction of anesthesia, insomnia, and acute manic states and delirium. The most dangerous adverse effect of the medication is respiratory depression that can be fatal.

A charge nurse on the mental health unit is making shift assignments to best utilize the team and implement effective care. The staffing for the shift includes a practical nurse (PN) and an AP. Which of the following tasks should the nurse delegate to the PN? a. Creating a care plan for a client who has schizophrenia b. Weighing a client who has bulimia nervosa c. Reinforcing teaching about medications for a client who has depression d. recording the intake of a client who is experiencing mania

c. Reinforcing teaching about medications for a client who has depression

A nurse is reviewing laboratory reports for a client who is taking risperidone. The nurse should identify that which of the following results indicates a potential adverse reaction to the medication? A. Elevated blood glucose B. Elevated WBC count C. Decreased platelet count D. Decreased aspartate transaminase (AST)

A. Elevated blood glucose The nurse should identify that all second-generation antipsychotic medications such as risperidone can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. If there is no change after 12 weeks, glucose should be monitored annually.

A nurse is assessing a client prior to administering lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4 lb) since the start of treatment C. Fine hand tremors in both hands D. Serum lithium level of 1.1 mEq/L

A. Report of nausea with frequent episodes of emesis Gastrointestinal upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. The nurse should assess the client for indications of dehydration, which further increases the risk of lithium toxicity.

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? A. The death was a result of violence. B. The client expresses anger over the loss. C. This is the client's first experience of the loss of a family member. D. The client demonstrates reorganization of behavior.

A. The death was a result of violence.

A mental health nurse is reviewing a process recording of a therapy session with a client. Which of the following statements should the nurse identify as an example of the communication technique of reflection? A. "I notice you are pulling on your hair when we discuss your dismissal." B. "That statement made by the other client appears to have upset you." C. "Since writing in your journal is frustrating, we should look at this activity more closely." D. "Give me an example of a time when you felt no one understood you."

B. "That statement made by the other client appears to have upset you." Reflective statements are useful in assisting a client with identifying emotions and ideas. This therapeutic communication technique validates the client's emotions and encourages the client to reflect more deeply on the emotion.

A nurse on a psychiatric unit is talking with a client when the client makes a sexual advance toward the nurse. Which of the following responses should the nurse make? A. "It's normal for you to have sexual feelings toward the staff." B. "You need to stop any type of sexual advances." C. "This behavior is unacceptable while I am your nurse." D. "What would your family think of this type of behavior?"

B. "You need to stop any type of sexual advances." The nurse should clearly identify behavioral expectations to help promote and maintain appropriate boundaries.

A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect? A. Low blood pressure B. Dilated pupils C. Conjunctival redness D. Decreased body temperature

B. Dilated pupils Dilated pupils are associated with the use of cocaine.

A nurse is assessing a client who was brought to the emergency department by a friend. The friend reports that the client inhaled a large amount of cocaine. Which of the following findings should the nurse expect? A. Depressed mood B. Hallucinations C. Severe hypotension D. Bradycardia

B. Hallucinations

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following clinical manifestations should the nurse expect? A. Sedation B. Rhinorrhea C. Bradycardia D. Hypothermia

B. Rhinorrhea The nurse should expect a client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations, such as yawning, sneezing, and abdominal pain.

A charge nurse is discussing ethics with a newly licensed nurse. Which of the following actions should the charge nurse include as an example of beneficence? A. Taking a continuing education course about recognizing risk factors of suicide B. Spending extra time reorienting a client who is experiencing command hallucinations C. Acknowledging and accepting a client's refusal of a psychotropic medication D. Describing the purpose, action, and side effects of a psychotropic medication

B. Spending extra time reorienting a client who is experiencing command hallucinations The nurse should include this action as an example of beneficence, which is the duty to act to promote the good of others. Reorienting a client who is experiencing command hallucinations is in the best interest of the client and can protect the client from harm.

A nurse is providing discharge teaching for a client who has a new prescription for doxepin. Which of the following adverse effects is associated with this medication? A. Weight loss B. Diarrhea C. Drowsiness D. Bradycardia

C. Drowsiness

A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine fumarate. Which of the following blood tests should be performed periodically? A. Potassium B. Uric acid C. Glucose D. Calcium

C. Glucose Clients taking quetiapine are at risk of abnormal glucose metabolism, which can result in diabetes mellitus. Therefore, the client should have glucose testing periodically.

A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following nursing actions is contraindicated for this client? A. Explaining that tube feeding will be necessary if the client refuses oral intake B. Weighing the client each day prior to any oral intake C. Permitting the client to spend some quiet time alone after each meal D. Refraining from commenting about the client's eating during meal times

C. Permitting the client to spend some quiet time alone after each meal The nurse should directly observe the client for a minimum of 1 hour following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for the plan of care.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. Which of the following medications may be administered safely while the client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

C. Valproic acid Valproic acid and lithium are both indicated for the treatment of bipolar disorder. The nurse may safely administer both of these medications to the client.

A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication can cause dependence." B. "I should take a dose of my medication when I start to feel anxious." C. "It's important for me to take my medication 30 min before bedtime." D. "I should expect to feel the full effect of my medication in 2 to 4 weeks."

D. "I should expect to feel the full effect of my medication in 2 to 4 weeks."

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A. "Can you tell me why you do not want to participate in the planned group activity?" B. "Do you understand that psychotropic medications cause weight gain?" C. "The aerobics class will be more effective at burning calories than walking." D. "It sounds like you have come up with an alternative exercise that works for you."

D. "It sounds like you have come up with an alternative exercise that works for you." The nurse is using therapeutic techniques of acceptance, giving recognition, and encouragement by supporting the client's idea of a way to exercise.

A nurse is providing teaching to the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will not set time limits for discussing her delusions." B. "We will avoid reacting to her command hallucinations." C. "She might lose weight due to her medications." D. "She might be having a relapse if she stops attending social events."

D. "She might be having a relapse if she stops attending social events." The family of a client who has schizophrenia should be taught the signs of relapse, including avoiding other people, sleep disturbances, difficulty concentrating, and being unable to tell reality from nonreality.

A nurse is providing teaching to a client who is scheduled to start taking valproic acid. Which of the following instructions should the nurse include? A. "You should expect the provider to decrease your dosage of valproic acid gradually." B. "You should take aspirin for pain while taking valproic acid." C. "You should undergo thyroid function tests every 6 months while taking valproic acid." D. "You should have your liver function levels monitored regularly while taking valproic acid."

D. "You should have your liver function levels monitored regularly while taking valproic acid." The nurse should inform the client of the need to monitor liver function levels due to the risk of hepatotoxicity while taking valproic acid. Current recommendations advise obtaining baseline levels and repeating tests every 2 months during the first 6 months of therapy.

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of this medication every 72 hr C. Offer the client a PRN NSAID while taking this medication D. Administer the medication at bedtime

D. Administer the medication at bedtime Donepezil is used to treat the manifestations of mild to moderate Alzheimer's disease. The nurse should administer this medication at bedtime to reduce the risk of injury due to bradycardia and syncope.

What medications are anticipated or contraindicated for Client iss alert and oriented, answers questions appropriately. Client noted to be continuously tapping foot, appears anxious and tearful. Reports continued manifestations of insomnia, difficulty concentrating, and feeling irritable. Also states has had little appetite. Client reports two recent episodes of feeling sweaty, short of air, shaky, nauseous, and "like my heart is beating out of my chest." Reports these manifestations started suddenly and lasted about 10 minutes. Denies feelings of sadness, hopelessness, or worthlessness. Weight 76.2 kg (168 lb), BMI 23.4. Lorazepam Dexmethylphenidate Alprazolam Sertraline Escitalopram

Lorazepam - anticipated Dexmethylphenidate - contraindicated Alprazolam - anticipated Sertraline - anticipated Escitalopram - anticipated When generating solutions, the nurse should identify that the provider may prescribe medications such as escitalopram, sertraline, alprazolam, or lorazepam for a client who has a panic disorder. Escitalopram and sertraline are antidepressant medications that also treat generalized anxiety disorder. Alprazolam and lorazepam are benzodiazepines that can be used as needed at the onset of a panic attack to decrease manifestations of panic and severe levels of anxiety. Dexmethylphenidate is a stimulant medication typically prescribed for attention deficit hyperactivity disorder.

3 days ago, 1000: Client is attending their first group therapy session with other clients to discuss coping strategies. The client is speaking loudly and interrupting other clients to discuss the weather and how studying weather patterns is the best way to cope. The nurse is responding to the client's actions during the group therapy session. The nurse should _____________ and ______________ a. inform the client they agree with their coping strategy b. allow group members to offer feedback to the client c. have the client reduce the number of topics discussed d. place the client in a seclusion room e. ask the client why they are interrupting so much

The nurse is responding to the client's actions during the group therapy session. The nurse should have the client reduce the number of topics discussed and allow group members to offer feedback to the client

The client was yelling that they could control the water during a mandatory evacuation order due to a hurricane. The client was wearing a mermaid costume and holding a sword. The partner states that the client has had erratic behavior for a week and has not been eating or sleeping. Client is brought to room. Client states that the hospital staff is plotting to destroy the world by not letting the client stop the hurricane because they have greater powers than Poseidon. The client has pressured speech and flight of ideas. Client reports that they think they hear a voice telling them to do whatever it takes to escape. The client is yelling, "Water is getting out; you better not pout, snout, route!" The nurse should first address the clients risk ______________ (injury, impaired socialization, imbalanced nutrition, sleep deprivation) due to ____________ (speech pattern, hallucinations, activity level, oral intake)

The nurse should first address the clients risk for injury due to hallucinations

Lithium Education to Notify Provider (select four) a. "I should let my provider know if I have diarrhea." b. "I should reduce my daily fluid intake." c. "I can stop taking this medication once I feel back to myself." d. "I should increase the amount of sodium in my diet." e. "A hand tremor is a sign that my medication level is too high." f. "I will need to monitor my medication blood levels often." g. "I should take my medication with meals."

a. "I should let my provider know if I have diarrhea." e. "A hand tremor is a sign that my medication level is too high." f. "I will need to monitor my medication blood levels often." g. "I should take my medication with meals."

A nurse on an acute mental health unit is prioritizing care for four clients. Which of the following clients should the nurse see first a. A client who has schizophrenia, is taking an antipsychotic medication, and has dystonia b. A client who has obsessive-compulsive disorder and continues ritualistic behavior c. A client who has borderline personality disorder and manipulates staff members d. Aclient who has depressive disorder and refuses to attend individual psychotherapy

a. A client who has schizophrenia, is taking an antipsychotic medication, and has dystonia

Potential Assessment Finding Anxiety Disorder Depressive Disorder Select Anxiety Disorder, Depressive Disorder, or Both a. Change in appetite b. Sudden onset episodes of tachycardia, diaphoresis, nausea c. Alteration in concentration d. Sleep disturbance

a. Change in appetite - Both b. Sudden onset episodes of tachycardia, diaphoresis, nausea - Anxiety c. Alteration in concentration - Both d. Sleep disturbance - Both

The client was yelling that they could control the water during a mandatory evacuation order due to a hurricane. The client was wearing a mermaid costume and holding a sword. Client is accompanied by their partner. The partner states that the client has had erratic behavior for a week and has not been eating or sleeping. Client is brought to room. Client states that the hospital staff is plotting to destroy the world by not letting the client stop the hurricane because they have greater powers than Poseidon. The client has pressured speech and flight of ideas. Client reports that they think they hear a voice telling them to do whatever it takes to escape. The client is yelling, "Water is getting out; you better not pout, snout, route!" Client Findings (select bipolar disorder or schizophrenia or both) a. Hallucinations b. Onset of findings c. Speech pattern d. Thought process

a. Hallucinations - Both b. Onset of findings - Bipolar Disorder c. Speech pattern - Both d. Thought process - Both

Education for Benzodiazepine (SATA) a. This medication can cause drowsiness and dizziness b. Do not take this medication more than prescribed due to the risk of dependence c. This medication can cause temporary hair loss d. Do not drive or operate machinery while taking this medication e. Do not consume alcohol while taking this medication.

a. This medication can cause drowsiness and dizziness b. Do not take this medication more than prescribed due to the risk of dependence d. Do not drive or operate machinery while taking this medication e. Do not consume alcohol while taking this medication.

A nurse is caring for a client who needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take? a. Explain the adverse effects the client might experience from the treatment. b. Verify the client gave consent voluntarily for the treatment. c. Describe the benefits of the treatment to the client. d. Outline possible alternatives of the treatmentfor the client.

b. Verify the client gave consent voluntarily for the treatment.