ATI RN Mental Health Online Practice 2023 B

NGN: A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event. The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? SELECT ALL THAT APPLY 1. "It is common for people who survived a traumatic event to experience feelings of anxiety." 2. "It is uncommon for people who survived a traumatic event to experience spiritual distress." 3. "You will have minimal problems performing your daily self-care tasks." 4. "You should seek help if you have thoughts of self-harm." 5. "A support group might be helpful to you during this time."

Correct = 1. "It is common for people who survived a traumatic event to experience feelings of anxiety." 4. "You should seek help if you have thoughts of self-harm." 5. "A support group might be helpful to you during this time."

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? 1. "It appears as though you would like to open the door." 2. "You will feel more comfortable after you've been here for a while." 3. "It is okay to not want to be here." 4. "You really shouldn't be pushing on the door."

Correct = 1. "It appears as though you would like to open the door." - This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

NSG: A nurse is caring for a client who has anorexia nervosa. A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? SELECT ALL THAT APPLY 1. BUN 2. Peripheral Edema 3. Sodium 4. Potassium 5. Glucose 6. Heart Rate 7. Bowel Movement 8. Skin Temperature 9. BMI 10. Blood Pressure

Correct = 1. BUN 3. Sodium 4. Potassium 6. Heart Rate 7. Bowel Movement 8. Skin Temperature 9. BMI

NGN: A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa. Click to highlight the information in the client's medical record that indicate that client's condition is deteriorating. (To deselect information, click on the information again.) 1. QT prolongation 2. Exercise regimen 3. Hematemesis 4. Temperature 5. Laxative use 6. BMI

Correct = 1. QT prolongation 2. Exercise regimen 3. Hematemesis 6. BMI

NSG: A nurse on an inpatient psychiatric unit is caring for a client who is experiencing alcohol withdrawal. The nurse is evaluating the client after interventions for alcohol withdrawal syndrome have been implemented. Which of the following findings indicate a positive response to therapy? SELECT ALL THAT APPLY 1. Withdrawn and Quiet Upon Awakening 2. Respiratory Rate 3. Slept with Minimal Disruption for 8 Hours 4. Heart Rate 5. Blood Pressure 6. Unable to Recall the Trip to the Facility 7. Temperature 8. Tremors

Correct = 2. Respiratory Rate 3. Slept with Minimal Disruption for 8 Hours 4. Heart Rate 5. Blood Pressure 7. Temperature 8. Tremors - Respiratory rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's respiratory rate has dropped from a high of 26/min to 22/min, indicating a positive response to therapy. - Slept with minimal disruption for 8 hr is correct. One of the major goals for a client who is experiencing alcohol withdrawal syndrome is sedation and rest. The client slept for 8 hr, indicating a positive response to therapy. - Heart rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's heart rate has dropped from 122/min to 95/min, indicating a positive response to therapy. - Blood pressure is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's blood pressure has decreased from 164/82 mm Hg to 124/62 mm Hg, indicating a positive response to therapy. - Temperature is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's temperature has decreased from a high of 39.1° C (102.4° F) to 38° C (100.4° F), indicating a positive response to therapy. - Tremors is correct. Tremors are a manifestation of alcohol withdrawal syndrome. The client's decreased tremor activity is an indication of a positive response to therapy.

NGN: A nurse in the emergency department (ED) is admitting a client who was dropped off at the door. The nurse is assessing the Client. Select the 5 findings that require follow-up... 1. Blood glucose level 2. WBC count 3. Nausea and vomiting 4. Respiratory rate 5. Oxygen saturation 6. GSC score 7. Temperature 8. Level of consciousness (LOC) 9. BAC

Correct = 3. Nausea and vomiting 4. Respiratory rate 7. Temperature 8. Level of consciousness (LOC) 9. BAC 3. Nausea and vomiting is correct. For a client who has ingested alcohol, nausea and vomiting can be an indication of alcohol toxicity, which can result in an alteration in vital signs. 4. Respiratory rate is correct. A respiratory rate of 11/min is below the expected reference range and can indicate alcohol toxicity in the client. 7. Temperature is correct. The client can experience a reduction of body temperature as a manifestation of alcohol toxicity. 8. Level of consciousness (LOC) is correct. A client who has an altered LOC following alcohol ingestion might be experiencing alcohol toxicity. 9. BAC is correct. A BAC of 340 mg/dL indicates alcohol toxicity. This value indicates a critical level.

A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness? 1. "I am going to order a wheelchair for when I'm unable to walk." 2. "I am going to stop paying my bills since I won't be around much longer." 3. "I wish you would go take care of somebody who actually needs you." 4. "I am sure I'll be able to continue to care for myself without help."

Correct = 1. "I am going to order a wheelchair for when I'm unable to walk." - The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates they have accepted the reality of their illness. This statement is an example of the acceptance, or final, stage of grief.

NGN: A nurse in the emergency department (ED) is admitting a client who was dropped off at the door. For each of the provider's potential prescriptions, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client... Potential Order: 1. Administer an anti-anxiety medication. 2. Monitor vital signs every 30 min. 3. Wake the client every 30 min for neurological assessment. 4. Initiate IV access. 5. Obtain CT scan of brain. 6. Obtain an Alcohol Use Disorders Identification Test (AUDIT).

Correct = Anticipated: 1. Administer an anti-anxiety medication. 2. Monitor vital signs every 30 min. 4. Initiate IV access. - The client is displaying agitation and reporting hallucinations and therefore requires anti-anxiety medication. - Vital signs should be monitored frequently to continually assess the client for peripheral circulatory collapse that can occur with alcohol withdrawal. - Treatment for alcohol withdrawal syndrome requires sedation to prevent seizure activity and circulatory collapse. This is best accomplished for the client via the IV route. Nonessential: 5. Obtain CT scan of brain. 6. Obtain an Alcohol Use Disorders Identification Test (AUDIT). - Although a head injury can mimic manifestations of alcohol withdrawal delirium, there is no indication that the client has had a head injury and requires a CT scan. - This screening tool is a self-reporting tool to assist a health care provider with gaining information, which can be used to develop a plan of care. This is not an appropriate prescription for the client at this time, as they are experiencing psychotic manifestations of acute alcohol withdrawal. Contraindicated: 3. Wake the client every 30 min for neurological assessment. - The treatment plan for this client should include sedation to encourage rest. The client does not require a neurological examination every 30 min.

NGN: A nurse on a mental health unit is admitting a client who has Bipolar Disorder. Complete the following sentence by using the list of options... Dropdown 1: "The first action the nurse should take to address the Client's ________ ... 1. Urine Output 2. Cardiovascular Injury 3. Noncompliance with Medication Therapy 4. Inability to Focus Dropdown 2: "due to the Client's ________ ." 5. Pressured Speech 6. Poor Recall of Last Food Intake 7. Constant Psychomotor Activity 8. Lithium Level

Correct = Dropdown 1: 2. Cardiovascular Injury Dropdown 2: 7. Constant Psychomotor Activity *When prioritizing hypotheses, the nurse should identify the greatest risk to the client is cardiovascular injury due to constant psychomotor activity. The client is pacing, moving arms and hands around dramatically, and is unable to sit still. This can increase the client's blood pressure and heart rate, which can indicate unexpected cardiovascular findings.

NGN: A nurse is caring for a Client who has an alcohol use disorder. Complete the following sentence by using the list of options... Dropdown 1: "The Client is at greatest risk for ________ 1. Dehydration 2. Violent Behavior 3. Ineffective Coping Dropdown 2: "as evidenced by the Client's ________ 4. Inability to Perform Simple Tasks 5. Loss of Appetite 6. Agitation

Correct = Dropdown 1: 2. Violent Behavior - The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcohol, which is causing them increasing agitation. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury. Dropdown 2: 6. Agitation - The client is at greatest risk of engaging in violent behavior as evidenced by the client's agitation, which can be indicated by pacing, restlessness, staring, silence, rigid posture, and clenched jaw. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury.

NGN: A nurse on a mental health unit is caring for a recently admitted client. For each potential assessment finding, click to specify if it is a positive or negative symptom of schizophrenia. Assessment Findings: 1. Delusions of Grandeur 2. Clang Associations 3. Alogia 4. Withdrawal from Social Activities 5. Catatonia 6. Absence of Intonation in Speech

Correct = Positive Symptoms: 1. Delusions of Grandeur 2. Clang Associations 5. Catatonia *Positive symptoms, the presence of symptoms that are not ordinarily present, include hallucinations, delusions, paranoia, and disorganized or bizarre thoughts, behaviors, or speech. Negative Symptoms: 3. Alogia 4. Withdrawal from Social Activities 6. Absence of Intonation in Speech *Negative symptoms, or the absence of something that should be present, include lack of goal-directed behavior, decrease in participation in social activities, and a flat affect.

NGN: A nurse in the emergency department (ED) is admitting a client who was dropped off at the door. For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major depressive disorder. Each finding may support more than one disease process. Client Assessment Findings: 1. Respiratory Rate 2. Weight Change 4. Level of Consciousness (LOC) 5. Mental Status 6. Nausea and Vomiting

Correct = Alcohol Toxicity: 1. Respiratory Rate 4. Level of Consciousness (LOC) 5. Mental Status 6. Nausea and Vomiting Major Depressive Disorder: 2. Weight Change 5. Mental Status

NGN: A nurse in the emergency department (ED) is reviewing prescriptions from the provider Complete the following sentence by using the lists of options... Dropdown 1. "The nurse should first ________ ," 1. Initiate Suicide Precautions 2. Repeat the Blood Glucose Level 3. Monitor Vital Signs Every 30 Minutes Dropdown 2. "followed by ________." 4. Administer Diazepam 5. Initiating IV Access 6. Administering Acetaminophen

Correct = Dropdown 1: 1. Initiate Suicide Precautions - The greatest risk to this client is self-injury. Therefore, the first action the nurse should take is to initiate suicide precautions. The client has a history of self-injury and indicates that they have had recent thoughts of harming themselves. Dropdown 2: 5. Initiating IV Access - The client has multiple manifestations of alcohol withdrawal syndrome. The primary treatment goal is to provide sedation and IV fluids. Therefore, the nurse must initiate the IV access before these medications can be administered.

NGN: A nurse in the emergency department (ED) is admitting a client who was dropped off at the door. Complete the following sentence by choosing from the lists of options. Dropdown 1. "The Client is at risk for developing ________ ..." 1. Respiratory Distress 2. Aspiration 3. Alcohol Withdrawal Syndrome Dropdown 2. "as evidenced by the Client's ________." 4. Heart Rate 5. Mental Status 6. Pulse Oximetry

Correct = Dropdown 1: 3. Alcohol Withdrawal Syndrome - The client had clear evidence of alcohol toxicity, including a BAC of 340 mg/dL. There has been no further alcohol intake since admission to the facility, increasing the client's risk for developing alcohol withdrawal syndrome. Dropdown 2: 5. Mental Status - A client who has had an abrupt cessation of alcohol intake will exhibit hand tremors and mental status changes, including agitation, irritability, and anxiety. These are all manifestations of alcohol withdrawal syndrome.

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? 1. A 35-year-old client who has major depressive disorder 2. A 50-year-old client who has a blood alcohol level of 80 mg/dL 3. A 17-year-old client who lives with friends 4. A 65-year-old client who just received a dose of morphine

Correct = 1. A 35-year-old client who has major depressive disorder - A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent. *A Client who is intoxicated cannot legally give informed consent. *Individuals younger than 18 years of age can only provide informed consent if they are married, pregnant, parents, or emancipated. *A Client who has just received morphine, an opioid analgesic, is functionally incompetent due to the medication's effect on the CNS.

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? 1. Allow the client time to formulate an answer. 2. Prompt the client to give a response. 3. Move on to the next client. 4. Offer the client a suggestion for a goal.

Correct = 1. Allow the client time to formulate an answer. - Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A nurse is admitting a client who has 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? 1. Clang Association 2. Word Salad 3. Neologism 4. Echolalia

Correct = 1. 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 a similar sound.

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? 1. Increased creatine phosphokinase (CPK) 2. Increased low-density lipoproteins (LDL) 3. Decreased fasting blood glucose 4. Decreased aspartate aminotransferase (AST)

Correct = 1. Increased creatine phosphokinase (CPK) - An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? 1. Shuffling Gait 2. Hypotension 3. Decreased WBC Count 4. Blurred Vision

Correct = 1. Shuffling Gait - Benztropine is used to treat parkinsonism manifestations, such as shuffling gait.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? 1. The client recently lost a grandparent in a motor vehicle crash. 2. The client's town was hit by a tornado. 3. The client's youngest child is leaving for college. 4. The client is ambivalent about their upcoming retirement.

Correct = 1. The client recently lost a grandparent in a motor vehicle crash. - The client experiences a situational crisis when an unexpected event occurs.

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? 1. The client reports command hallucinations. 2. The client is exhibiting echolalia. 3. The client reports loss of motivation. 4. The client is exhibiting blunted affect.

Correct = 1. 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 reviewing the medical record or a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication that the client require hospitalization? 1. Total body fat 8.7% 2. Potassium 3.6 mEq/L (3.5 to 5 mEq/L) 3. Temperature 36.1° C (96.9° F) 4. Heart rate 54/min

Correct = 1. 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 finding to the provider.

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weights 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct = 14 mL - Follow these steps for the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/Dose = ? Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) X mL/Dose = 5 mL/10 mg Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. X mL/Dose = 5 mL/10mg x 27.5 mg/1 kg x 1 kg/2.2 lb x 110 lb/ 1 Dose Step 4: Solve for X. X mL/dose = 13.75 mL/Dose Step 5: Round if necessary. 13.75 mL/Dose = 14 mL/Dose Step 6: Determine whether the amount to administer makes sense. If there are 10 mg/5 mL and the prescription reads 0.55 mg/kg, it makes sense to administer 14 mL. The nurse should administer chlorpromazine syrup 14 mL PO.

A nurse is teach coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? 1. "I will spend extra time at work to keep from feeling depressed." 2. "I will talk about my feelings with a close friend." 3. "I will be able to learn how to prevent my partner's attacks." 4. "I will use meditation instead of taking my antidepressant."

Correct = 2. "I will talk about my feelings with a close friend." - Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

A nurse is teaching a client who has depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? 1. "You might notice an increase in saliva while taking this medication." 2. "You might experience difficulties with sexual functioning while taking this medication." 3. "You should expect an improvement in symptoms of depression in 3 to 4 days." 4. "You may notice a temporary ringing in the ears when starting this medication."

Correct = 2. "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 is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and fear of gaining weight. The Client states, "I'm so fat I can't even stand to look at myself.". Which of the following therapeutic responses demonstrates the nurse's use of summarizing? 1. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." 2. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." 3. "You don't want to look at yourself because you think you are fat." 4. "You and I can work together to overcome your fears of gaining weight."

Correct = 2. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." - The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? 1. A school-age child who has bruises on the knees 2. An older adult client who is bedbound and has a stage IV pressure ulcer 3. An adolescent who has a vaginal candida infection 4. A young adult who is pregnant and has a sprained ankle

Correct = 2. An older adult client who is bedbound and has a stage IV pressure ulcer - A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? 1. Tell the client to talk less or risk being removed from the meeting. 2. Ask group members to discuss their feelings about this client's monopolizing behavior. 3. End the group meeting and take the client aside to discuss the disruptive behavior. 4. Focus on other group members and ignore the client who is doing all the talking.

Correct = 2. Ask group members to discuss their feelings about this client's monopolizing behavior. - This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? 1. Orient the client to person, place, and time. 2. Assist the client with deep-breathing exercises. 3. Calm the client by using therapeutic touch. 4. Have the client sit alone in a quiet room.

Correct = 2. Assist the client with deep-breathing exercises. - Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. *It is recommended that the nurse stay with a client who is experiencing panic anxiety to ensure the client's safety.

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? 1. Have the client participate in a morning aerobics group. 2. Encourage frequent rest periods throughout the day. 3. Provide a distraction such as television at night. 4. Offer the client hot chocolate at bedtime.

Correct = 2. Encourage frequent rest periods throughout the day. - A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion. *Direct client to areas with minimal activity to decrease stimulation. *The nurse should integrate interventions to promote sleep: Soft Music, Quiet Room, Warm Milk

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? 1. Include a liquid supplement with meals. 2. Identify the client's trigger foods. 3. Allow the client at least 1 hr for each meal. 4. Weigh the client at bedtime each day.

Correct = 2. Identify the client's trigger foods. - The nurse should identify the trigger foods that initiate the client's binge and assist the client to understanding their thoughts and behavior that relate to the food. The nurse should limit the client's meal times to about 30 min to prevent putting excessive focus on food. The nurse should weigh the client immediately after they wake up and void and prior to oral intake. The nurse should weigh the client daily for the first week and then three times per week. *The nurse should include a liquid supplement for a client who is below their ideal body weight and might not be able to eat solid foods at first or might need the additional nutrition to gain weight.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? 1. Sedation 2. Rhinorrhea 3. Bradycardia 4. Hypothermia

Correct = 2. Rhinorrhea - The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.

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? 1. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. 2. The client reports an inability to breathe easily. 3. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL (74 to 106 mg/dL) 4. The client reports having recently started smoking cigarettes.

Correct = 2. 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 providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching? 1. "I will avoid social events until my partner has completed treatment." 2. "It is important for me to focus my attention on my partner's addiction." 3. "I will not take charge of my partner's work responsibilities." 4. "I want my partner to promise to change addictive behaviors."

Correct = 3. "I will not take charge of my partner's work responsibilities." - The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? 1. Complete documentation about the client's status every hour while they are in restraints. 2. Maintain the client in restraints for a minimum of 4 hr. 3. Apply restraints when other means of managing the client's behavior have failed. 4. Request that the provider assess the client within 8 hr of the application of restraints.

Correct = 3. Apply restraints when other means of managing the client's behavior have failed. - According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints. *Document Client's status, behavior, vitals, and address the client's physical and safety needs every 15 minutes. *Maximum amount of time an adult should remain in restrains is 4 hours. *The use of restrains requires a providers prescription. In emergent cases the prescription can be obtain after the restrains have been applied. However, the provider must evaluate the client within 1 hour of the initiation of the restrains.

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take? 1. Ask the client to identify the bomb in the room. 2. Initiate disaster protocols per facility policies and procedures. 3. Assess the client for evidence of a perceptual disturbance. 4. Convince the client that there is no bomb in their room.

Correct = 3. 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. *Asking the client to identify the bomb in the room is an inappropriate action because the nurse is responding as if the hallucination is real. *Without evidence of a disaster on a mental health unit, it is inappropriate to initiate disaster protocols. *Trying to convince the client that there is not a bomb in their room negates the client's experience.

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? 1. Offering Self 2. Use of Silence 3. Attention to Body Language 4. Reflection of Feelings

Correct = 3. Attention to Body Language - Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.

A nurse is preparing to participate in an interdisciplinary conference for a client who has a bipolar disorder. Which of the follow behaviors is the priority for the nurse to report to the treatment team? 1. Calling Family Members 2. Spending Time Alone 3. Giving Away Possessions 4. Excessive Crying

Correct = 3. Giving Away Possessions - Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to spot taking the medication? 1. Sore throat 2. Photophobia 3. Hand tremors 4. Constipation

Correct = 3. 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. *Diarrhea is an early manifestation of lithium toxicity

A nurse obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? 1. Raise the pitch of the voice when speaking to the client. 2. Begin the interview by explaining the plan of care. 3. Interview the client in a private setting. 4. Ask the client to complete a detailed questionnaire.

Correct = 3. Interview the client in a private setting. - The nurse should interview clients in a private place when asking questions regarding client health. *The nurse should use a lower pitch of voice when speaking because older adult clients are typically able to hear words that are spoken with a lower pitch. *The nurse should begin the interview by asking the client to identify their needs and concerns. This data is then used to create a personalized plan of care. *The nurse should limit the number of items on a questionnaire when gathering data from an older adult client.

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indications of a boundary issue? 1. An adolescent family member who questions parental authority 2. A family with three generations in the same household 3. Older children who are responsible for their younger siblings 4. Two adults and their children from prior relationships in the same household

Correct = 3. Older children who are responsible for their younger siblings - This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.

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? 1. Schedule the client for group therapy sessions. 2. Maintain consistent rules. 3. Provide frequent high-calorie snacks. 4. Avoid the use of value judgments.

Correct = 3. Provide frequent high-calorie snacks. - The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? 1. Controls anger outbursts to avoid being placed in seclusion 2. No longer exhibits a fear of social or public situations 3. Refrains from manipulating others to earn dining room privileges 4. Imitates the therapist's use of a relaxation technique

Correct = 3. 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 creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? 1. Document the client's behavior every 8 hr. 2. Limit the client's fluid intake to 50 mL/hr. 3. Renew the prescription for the client every 4 hr. 4. Toilet the client every 4 hr.

Correct = 3. Renew the prescription for the client every 4 hr. - The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

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? 1. Male Gender 2. Hyperthyroidism 3. Substance Use Disorder 4. Being Married

Correct = 3. Substance Use Disorder - The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? 1. The client will taking prescribed medications as scheduled. 2. The client will express feelings of frustration. 3. The client will refrain from self-mutilation. 4. The client will participate in group therapy.

Correct = 3. 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.

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? 1. "I put in extra hours at work so I won't think about drinking." 2. "I know that wine is good for my heart, so that's why I drink some each evening." 3. "I make up for my drinking by taking my partner on nice vacations." 4. "I am able to go to work every day, so I don't have a problem."

Correct = 4. "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 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? 1. "Information regarding clients should remain confidential until after their death." 2. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." 3. "As long as client identity is disguised, their health information can be shared between professionals on the internet." 4. "In the event a client threatens harm to others, medications can be administered without consent."

Correct = 4. "In the event a client threatens harm to others, medications can be administered without consent." - The charge nurse should inform the participants that medications can be administered without consent if a client threatens harm to others. The nurse should always protect the health and safety of their clients, even when a client's safety is threatened by another client.

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? 1. "It will be better for you to keep busy to avoid thinking about your child's death." 2. "You will complete the grieving process about a year after your child's death." 3. "The grief process will start once your child actually dies." 4. "It is not uncommon to feel angry toward yourself or others."

Correct = 4. "It is not uncommon to feel angry toward yourself or others." - Feelings of blame and anger toward oneself or others are an expected reaction when a client is experiencing a loss. The grief process has no timeline. It varies for each individual. The client can begin anticipatory grieving during the child's illness.

A nurse in an emergency department is caring for an adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? 1. "They work so hard at ballet. Will they still be able to perform?" 2. "They're happier with their appearance now that they've lost some weight." 3. "They told me they were tired, so I did their chores for them today." 4. "They won't let me take the trash from their room. I'm concerned about what they have in there."

Correct = 4. "They won't let me take the trash from their room. I'm concerned about what they have in there." - The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? 1. Blurred vision 2. Orthostatic hypotension 3. Dry mouth 4. Acute dystonia

Correct = 4. Acute dystonia - The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what what to do.". Which of the following actions should the nurse take? 1. Tell the client that the voices do not really exist. 2. Touch the client to help reduce feelings of anxiety. 3. Instruct the client to go to a quiet room when the voices start talking. 4. Ask the client what the voices are saying.

Correct = 4. 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 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? 1. Obtain the weight of a client who has bipolar disorder and is experiencing mania. 2. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. 3. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. 4. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

Correct = 4. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted 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 wound, and collect data regarding the healing of the wound.

A home health nurse is assessing an older adult client whose sibling is their primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? 1. Increased Confusion 2. Sleep Disturbances 3. Cluttered Environment 4. Inappropriate Dress

Correct = 4. Inappropriate Dress - Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? 1. Advise the client to take frequent sips of water. 2. Recommend that the client exercise regularly. 3. Consult a dietitian for a calorie-controlled diet plan. 4. Instruct the client to avoid driving during initial therapy.

Correct = 4. 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. The nurse should advise the client to take frequent sips of water due to the adverse effect of dry mouth. However, this is not the nurse's priority intervention. The nurse should advise the client to exercise regularly due to the adverse effects of weight gain and constipation. However, this is not the nurse's priority intervention. The nurse should consult a dietitian for a calorie-controlled diet plan due to the adverse effect of weight gain. However, this is not the nurse's priority intervention.

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over the counter medications that the client reports taking should alert the nurse to a potential adverse reaction? 1. Lansoprazole 2. Naproxen 3. Magnesium hydroxide 4. Phenylephrine

Correct = 4. Phenylephrine - Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

A nurse is planning care for a 7 year old child who has ADHD. Which of the following interventions should the nurse identify as the priority? 1. Decrease distractions during meal times. 2. Provide positive feedback when the child completes a task. 3. Clearly identify consequences for unacceptable behavior. 4. Remove unnecessary equipment from the child's surroundings.

Correct = 4. 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.

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? 1. Confront the staff member. 2. Encourage the client to report the incident. 3. Document the incident in the client's health record. 4. Report the occurrence to the charge nurse.

Correct = 4. Report the occurrence to the charge nurse. - It is the responsibility of the charge nurse and the nurse manager to confront the staff member about the derogatory comments made to the client. *It is not the responsibility of the nurse to discipline other staff members. *The incident should not be documented in the Client's health record.

A nurse is caring for an older adult who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? 1. Move the client to a room near the nurses' station. 2. Limit visitors until the client is oriented to the environment. 3. Tell the client that their partner is deceased. 4. Talk with the client about activities they enjoyed with their partner.

Correct = 4. Talk with the client about activities they enjoyed with their partner. - Talking about positive experiences can help distract the client from their disorientation.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? 1. Amenorrhea 2. Lanugo 3. Cold Extremities 4. Tooth Erosion

Correct = 4. Tooth Erosion - A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.