psych ATI practice assessment A
51. 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 put in extra hours at work so I won't think about drinking." -"I know that wine is good for heart, so that's why I drink some each evening." -"I make up for my drinking by taking my partner on nice vacations." -"I am able to go to work every day, so I don't have a problem."
"I am able to go to work every day, so I don't have a problem." *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 wish I had been nicer and more generous with my wife before she died." -" I told my wife to go to the doctor, but she wouldn't listen to me." - "I think about my wife all the time when I go on outings with my family." -" I feel so empty without my wife but it's hard to get up every morning."
"I feel so empty without my wife but 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.
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." -"I should discontinue the lithium when I begin to feel better." -"I need to be careful to avoid becoming addicted to lithium." -"I can skip a dose of medication if my stomach is upset."
"I should eat a regular diet with normal amounts of salt and fluids." *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 the lithium excretion, which can lead to toxicity.
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by family member indicates manipulative Behavior? -"Do my homework for me. I won't bother you for the rest of the day" -"Mom is always upset" -"It's not the children's fault. It's mine" -_____
"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 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? -"Information regarding clients should remain confidential until after their death" -"Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states" -"As long as the client identity is Disguised, their health information can be shared between professionals on the internet." -"In the event client threatens harm to others, medications can be administered without consent."
"In the event client threatens harm to others, medications can be administered without consent." *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 clients perfect and without a court order.
38. 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? -"I'm relieved now that my financial affairs are in order." -"It is easier to talk about my feelings now." -"Suddenly, I have enough energy to do anything I want." -"Thank you for always taking such good care of me."
"It is easier to talk about my feelings now." *When clients express their feelings, this indicates a positive treatment outcome.
60. 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 will be better for you to keep busy to avoid thinking about your child's death." -"You will complete the grieving process about a year after your child's death." -"The grief process will start once your child actually dies." -"It is not uncommon to feel angry toward yourself or others."
"It is not uncommon to feel angry toward yourself or others." *Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing 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 will enhance the therapeutic effects of this treatment." -"Succinylcholine is given to reduce muscle movements during therapy." -"Succinylcholine will decrease the anxiety level that you might experience with this treatment." -"Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure."
"Succinylcholine is given to reduce muscle movements during therapy." *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 notice an increase in saliva while taking this medication." - "You might experience difficulties with sexual functioning while taking this medication." - "You should expect an improvement in symptoms of depression in 3 to 4 days." - " You make noticed a temporary ringing in the ears when starting this medication."
"You might experience difficulties with sexual functioning while taking this medication." *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 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 mmHg and a temperature of 39.9 degrees C (103.8 F). which of the following actions should the nurse take first? - administer phentolamine 5 mg IV to the client - apply a hypothermic blanket to the client - determine the client's prescribed medication regimen - initiates IV access for the client
- determine the client's prescribed medication regimen 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.
the nurse is preparing to administer chlorpromazine 0.55 mg/ kg Po to an adolescent who weighs 110 lbs. available is chlorpromazine syrup 10 mg/ 5 ml. how many should the nurse administer? ( Round to the nearest whole number. Use the leading zero if it applies. Do not use a trailing zero.)
14 ml 110 lb x (1 kg/2.2 lb) = 50 kg50 kg x 0.55 mg = 27.5 mg27.5 mg x(5 mL/10 mg) = 14 mL
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? -A client refuses electroconvulsive therapy after signing the consent form. -A client who was voluntarily admitted left the unit against medical advice. -A client was administered one-half of the prescribed dose of medication. - a client was placed in restraints after attempts to de-escalate aggressive behaviors failed
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? -A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. -A client who has depression reports having a lack of interest in assisting their partner in the care of their children. -A client who has borderline personality disorder threatened to harm their roommate. -An adolescent client who has anorexia nervosa has a BMI of 17.
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
59. A nurse is caring for a group of clients. Which of the following findings should the nurse report? -A client who is taking clozapine and has a WBC count of 7,500/mm3 -A client who is taking lamotrigine and has developed a rash. -A client who is taking valproate and has a platelet count of 150,000/mm3 -A client who is taking lithium and has a lithium level of 1.2 mEq/L
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 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? -Feelings of remorse -Extended periods of depression -Deficits in intellectual functioning -Aggression towards animals.
Aggression towards animals. *The nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder.
54. 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. -Prompt the client to give a response. -Move on to the next client. -Offer the client a suggestion for a goal.
Allow the client to formulate an answer. *Slowed response time is common in client who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.
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? -Delusions -Neologisms -Anhedonia - Echopraxia
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 is planning to care for 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 priority? -Arrange one-to-one observation fro the client. -Encourage interaction with the client's peers. -Administer medication for depressive disorder. -Encourage the client to attend a support group.
Arrange one-to-one observation of the client. *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 to tells the nurse, " I hear voices telling me what to do." Which of the following actions should the nurse take? -Tell the client that the voices do not really exist. -Touch the client to help reduce feelings of anxiety. -Instruct the client to go to a quiet room when the voices start talking. -Ask the client what the voices are saying.
Ask the client what the voices are saying. *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 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, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take? -Call the family member to the side to inquire if they have questions or concerns about the treatment plan. -Advice of family member that this treatment plan has been developed specifically for the client to follow. -Ask the family member if they have any thoughts or questions about the treatment plans. -Document that the family member does not support the medication treatment plan.
Ask the family member if they have any thoughts or questions about the treatment plans. *This action involves a family member and allows them a venue to communicate without 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 the room by a family member during visiting hours. Which of the following should the nurse take? -Ask the client to identify the bomb in their room. -Initiate disaster protocols per facility policies and procedures. -Assess the client for evidence of a perceptual disturbance. -??
Assess the client for evidence of a perceptual disturbance. *The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions.
39. 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? -Taking the oral medication buprenorphine to prevent alcohol use. -Attending a relapse prevention group several times each week -Beginning a methadone treatment program at a local center -Living with their parent, who has promised to keep them away from alcohol
Attending a relapse prevention group several times each week *The nurse should identify that the most effective strategy for relapse prevention is a 12-step program, such as Alcoholics Anonymous.
53. 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? -Offering self -Use of silence -Attention to body language -Reflection of feelings
Attention to body language *Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.
43. 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? -Ensure a family member can be present during treatment. -Increase fluid intake for 24 hours before the treatment starts. -Change position slowly when the treatment is complete. -Avoid looking directly at the light during treatment.
Avoid looking directly at the light during treatment. *Light therapy, or phototherapy, can cause sensitivity to light. To minimize this effect, the client should avoid looking directly at the light.
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? -Obtain the weight of a client who has bipolar disorder and is experiencing mania. -Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. -Monitor the cardiovascular status of a client who is experiencing serotonin syndrome -Change the dressings of a client who has borderline personality disorder and superficial self-inflected wounds.
Change the dressings of a client who has borderline personality disorder and superficial self-inflected wounds. *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 wounds, 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 -Word salad -Neologism -Echolalia
Clang association *The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have similar sounds.
56. 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? -Reduced appetite -Fatigue -Dark urine -Sweating
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.
20. 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 -Clonidine 0.1 mg transdermal patch -Naltrexone 380 mg IM -Bupropion 150 mg PO
Diazepam 5 mg IV bolus *The greatest risk to the client 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. -Request a prescription for IV lorazepam. -Request that another nurse attempt to administer the lorazepam. -Place the lorazepam in the client's food.
Do not administer the lorazepam. *Clients who are in a facility due to an involuntary 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 -Self-sacrificing -Suspicious of others - Grandiosity
Emotional lability *Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who has 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? - participate in the morning aerobics group. - Encourage frequent rest periods throughout the day. - provide a distraction such as television at night. - offer the client hot chocolate at bedtime
Encourage frequent rest periods throughout the day. * a client with experiencing acute Mania is at risk for Sleep disturbances the might go for extended periods of time without sleep. Encouraging. The breast throughout the day, but the rest 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. -Allow the client to eat independently in their room. -Weigh the client twice-weekly. - measure the client's vital signs once each day
Encourage the client to drink 125 mL of fluid each hour while awake. *Nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.
55. 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? (Select all that apply) -Feelings of hopelessness -Pressured speech -Grandiosity -Anhedonia -Flat facial expression
Feelings of hopelessness, Anhedonia, Flat facial expression Pressured speech and grandiosity are signs of mania
58. 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? -Inability to recognize family members. -Chooses clothing that is inappropriate for the weather. -Exhibits a change in personality. -Frequently misplaces objects.
Frequently misplaces object. *According to the 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 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 - administer a beta blocker intravenously - position the client in a low Fowler's position - place a cooling blanket over the client
Gather supplies for endotracheal intubation * 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 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 it expected adverse effect that might have caused the client to stop taking medication? - Sore throat - Photophobia - Hand tremors - Constipation
Hand tremors *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.
52. A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? -Polyphagia -Hypertension -Decreased temperature -Depressed mood
Hypertension *Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperatures, energy levels, and metabolism.
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? - increased confusion -sleep disturbances -cluttered environment -inappropriate dress
Inappropriate dress *clothing that is soiled for 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? -Advise the client to take frequent sips of water. -Instruct the client to avoid driving during initial therapy. -Consult a dietitian for a calorie-controlled diet plan. -Recommend that the client exercise regularly.
Instruct the client to avoid driving during initial therapy. *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.
48. A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? -Raise the pitch of the voice when speaking to the client. -Begin the interview by explaining the plan of care. -Interview the client in a private setting. -Ask the client to complete a detailed questionnaire.
Interview the client in a private setting. *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? -Diarrhea -Heavy menstrual bleeding -Tachycardia -Orthostatic hypotension
Orthostatic hypotension *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 plan? -Promote the use of music to compete with the client's auditory hallucinations. -Inform the client that the auditory hallucinations are not real. -Avoid asking the client if they are experiencing auditory hallucinations. -Instruct the client on the use of voice recognition regarding the auditory hallucinations.
Promote the use of music to compete with the client's auditory hallucinations. *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 is planning care for a newly admitted client who has bipolar disorder and is experiencing Mania. Which of the following is the priority action by the nurse? - Schedule the client for group therapy sessions. - Maintain consistent rules. - Provide frequent high-calorie snacks. -??
Provide frequent high-calorie snacks. *The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the clients need for adequate nutrition. Therefore, providing high calorie snacks is the priority action for the nurse to take.
57. A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following behaviors indicates effectiveness of the therapy? -Controls anger outbursts to avoid being placed in seclusion. -No longer exhibits a fear of social or public situations. -Refrains from manipulating others to earn dining room privileges. -Imitates the therapist's use of a relaxation technique.
Refrains from manipulating others to earn dining room privileges. *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 priority? -Decrease distraction during meal times. -Provide positive feedback when the child completes a task. -Clearly identify consequences for unacceptable behavior. -Remove unnecessary equipment from the child's surroundings.
Remove unnecessary equipment from the child's surroundings. *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.
37. 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? -Confront the staff member -Encourage the client to report the incident. -Document the incident in the client's health record. -Report the occurrence to the charge nurse.
Report the occurrence to the charge nurse. *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 for several days. Which of the following resources should the nurse recommend to the caregiver? -Respite care -Partial hospitalization -Adult day care program -_________
Respite Care *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 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? - Behave in a friendly manner toward the client - Set realistic limits on the client's behavior - Show respect for the clients need for isolation - Act as a role model for assertiveness
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.
33. A nurse is caring for a client who has schizophrenia and begin taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer Benztropine 2mg IM? - Shuffling gait - Hypotension - Decreased WBC count - Blurred vision
Shuffling gait *Benztropine is used to treat Parkinsonism manifestations, such as shuffling gait.
50. 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 -Saw palmetto -Echinacea -Ginkgo
St John's wort *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 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? -Male gender -Hyperthyroidism -Substance use disorder -Being married
Substance use disorder *The nurse should identify that clients who have substance use disorder are at an increased risk for the development of depressive disorders.
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? -Move the client to a room near the nurses' station. -Limit visitors until the client is oriented to the environment. -Tell the client that their partner is deceased. -Talk with the client about activities they enjoyed with their partner.
Talk with the client about activities they enjoyed with their partner. *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. - The client is attempting to manipulate the nurse. - The client is physically attracted to the nurse. - The client needs to feel accepted by the nurse
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.
While observing group therapy, the nurse recognizes that a client's 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 -The client demonstrates a dedication to their job that excludes time for leisure activities -The client appears to have a rigid set of rules -The client has difficulty starting new relationships unless they feel accepted
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
The nurse 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. -The client's town was hit by a tornado. -The client's youngest child is leaving for college. -The client is ambivalent about their upcoming retirement.
The client recently lost a grandparent in a motor vehicle crash. *The client experiences a situational crisis when an unexpected event occurs.
35. 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's chart indicates a 1.36 kg (3 lb) weight gain in 1 month. -The client reports an inability to breathe easily. -The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. -The client reports having recently started smoking cigarettes.
The client reports an inability to breathe easily. *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 is exhibiting echolalia. -The client reports command hallucinations. -The client reports loss of motivation -The client is exhibiting blunted affect.
The client reports command hallucinations. *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 take prescribed medications as scheduled. -The client will express feelings of frustration. -The client will refrain from self-mutilation. -The client will participate in group therapy.
The client will refrain from self-mutilation. *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.
36. 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% -Potassium 3.6 mEq/L -Temperature 35.8 C (96.4 F) -Heart rate 54/min
Total body fat 8.7% *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 findings to the provider.
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 fasting blood glucose level of 80 mg DL -A client who has a sodium level of 128 mEq/l -A client who has a b u n 18 mg/dl -A client who has a potassium level of 3.6 mEq/l
a client who has a sodium level of 128 mEq/l * is sodium level of 128 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
