Mental Health ATI
A nurse is providing medication teaching to a patient who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching? A. "You should change positions slowly while taking this medication." B. "This medication is prescribed to help overcome alcohol addiction." C. "You should omit foods containing oxalates while taking phenelzine." D. " You should avoid drinking liquids after your evening meal."
Answer: A. "You should change positions slowly while taking this medication." Rationale: Clients should change positions slowly while taking an MAOI due to the risk of orthostatic hypotension. Lightheadedness and fainting are common when taking phenelzine.
A nurse is reviewing abnormal lab values for four patient who have schizophrenia and take clozapine. For which of the following patients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued? A. A patient who has a WBC of 2,900 cells/mm^3 B. A patient who has a hematocrit of 55% C. A patient who has a serum potassium of 3.3 mEq/L D. A patient who has a BUN of 22 mg/dL
Answer: A. A patient who has a WBC of 2,900 cells/mm^3 Rationale: A white blood cell count of 2,900 cells/mm3 is below the normal reference range of 5000 to 10000 cells/mm3 . The client who takes clozapine is at risk for agranulocytosis; therefore, a client who has a WBC of less than 3000 mm3 should have clozapine withheld and treatment stopped until the WBC returns to normal. Clozapine should be permanently stopped if a client's WBC falls below 2000 mm3.
A nurse is preparing to administer selegiline for a patient who is admitted with major depression. Which of the following actions should the nurse take? A. Apply to dry skin on the patient's upper thigh B. Administer subcutaneously in the patient's abdomen using a 27 gauge needle C. Give medication orally at bedtime to promote sleep D. Inject the medication intramuscularly in a large muscle.
Answer: A. Apply to dry skin on the patient's upper thigh Rationale: Selegiline, a monoamine oxidase inhibitor (MAOI) is administered only by the transdermal route to treat depression. It can be administered orally to treat Parkinson's disease and other disorders.
A nurse is caring for a patient who is experiencing alcohol withdrawal. Which medication should the nurse administer first given the following information? -Graphic Record: HR 110/min; BP 170/96 mmHg; Temp. 38.9C (102F) - History and Physical: Client states he consumed alcohol 12 hr prior to admission; Has a 2 pack/day smoking hx - Progress reports: tremors of hands and fingers bilaterally; emesis of 30 mL bile-colored fluid; Patient is restless and unable to sit still; patient is diaphoretic and has flushed skin. A. Diazepam 5 mg IV bolus B. Clonidine 0.1 mg transdermal patch C. Naltrexone 380 mg IM D. Bupropion 150 mg PO
Answer: A. Diazepam 5 mg IV bolus Rationale: The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations.
A nurse caring for a patient who has a history of substance abuse disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the patient refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? A. Do not administer B. Request a prescription for IV lorazepam C. Request that another nurse attempt to administer lorazepam D. Place the lorazepam in the patient's food
Answer: A. Do not administer Rationale: Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment. Therefore, the nurse should hold the medication and document the client's refusal.
A nurse is caring for a patient who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the patient for which of the following adverse effects? A. Dysrhythmias B. Cataracts C. Pancreatitis D. Bleeding
Answer: A. Dysrhythmias Rationale: Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol. There is a risk for cardiac arrest due to torsades de pointes.
A nurse is providing teaching for a patient who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching? A. Increase your fluid and fiber intake to prevent constipation. B. Have your blood pressure checked frequently for hypertension C. Expect to have your blood checked weekly for a serum electrolyte imbalances D. Increase caloric intake to prevent weight loss
Answer: A. Increase your fluid and fiber intake to prevent constipation.
A nurse is caring for a patient who has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed? A. Thyroid hormone assay B. Liver function tests C. Erythrocyte sedimentation rate D. Complete blood cell count.
Answer: A. Thyroid hormone assay Rationale: Thyroid testing is important because long-term use of Lithium may lead to thyroid dysfunction.
A nurse is reviewing the medical record of a patient who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the patient requires hospitalization? A. Total body fat 8.7% B. Potassium 3.6 mEq/L C. Temperature 36.1 C (96.9F) D. Heart rate 54/min
Answer: A. Total body fat 8.7% Rationale: The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider.
A nurse in a hospital is caring for a patient who has agoraphobia. The nurse should evaluate that the patient is making progress when the patient is able to attend A. a picnic in a local park B. daily group therapy sessions C. recreational therapy in the day room D. lunch in the hospital cafeteria with family
Answer: A. a picnic in a local park
A newly admitted patient who has bipolar disorder and is experiencing mania. Which of the following medications should the nurse realize is expected to reduce the patient's mania? A. Fluvastatin B. Carbamazepine C. Lorazepam D. Propranolol
Answer: B Carbamazepine Rationale: Carbamazepine, an antiseizure medication and a mood stabilizer, is prescribed to treat and prevent mania in clients who have bipolar disorder.
A nurse is caring for a patient who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the patient may be experiencing tardive dyskinesia as an adverse reaction when the patient exhibits which of the following? (Select all that apply). A. Urinary retention and constipation B. Tongue thrusting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Extreme sedation and lethargy F. Repetitive involuntary movements
Answer: B, D, F
A nurse is planning care for a patient who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? A. Have the patient participate in a morning aerobics group. B. Encourage frequent rest periods throughout the day C. Provide a distraction such as TV at night D. Offer the patient hot chocolate at bedtime
Answer: B. Encourage frequent rest periods throughout the day Rationale: A patient who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.
A nurse in a mental health clinic is planning care for a patient who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? A. Advice the patient to take frequent sips of water B. Instruct the patient to avoid driving during initial therapy C. Consult a dietitian for a calorie-controlled diet plan D. Recommend that the patient exercise regularly
Answer: B. Instruct the patient to avoid driving during initial therapy. Rationale: The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.
A nurse reviews the laboratory report for a patient who is receiving lithium three times daily PO. The patient's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following? A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level. B. The lithium level is at the toxic level. C. The lithium level is below the therapeutic treatment level D. The lithium level is within the therapeutic level for initial treatment.
Answer: B. The lithium level is at the toxic level. Rationale: A blood lithium level greater than 1.5 mEq/L indicates toxicity. The nurse should monitor the client for GI manifestations, coarse hand tremor, confusion, drowsiness, and should withhold the lithium and notify the provider. A therapeutic initial blood level of lithium is 0.8 to 1.4 mEq/L. Blood levels for lithium maintenance should be between 0.4 and 1.3 mEq/L.
A nurse is caring for a patient who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the patient may be experiencing tardive dyskinesia when the patient exhibits which of the following? (Select all that apply). A. Urinary Retention and constipation B. Tongue thrusting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements
Answer: B. Tongue thrusting and lip smacking - Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as tongue thrusting and lip smacking. D. Facial grimacing and eye blinking - Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as facial grimacing and eye blinking. E. Involuntary pelvic rocking and hip thrusting movements - Repetitive, irregular, and involuntary movements of the head, neck, trunk, and extremities can occur in tardive dyskinesia.
The nurse is evaluating patient teaching who has newly diagnosed depression and a new prescription for bupropion. Which of the following statements by the patient indicates an understanding of the teaching? A. "I may develop a slow heartbeat while taking this medication." B. "I can drink one glass of wine each day with dinner while taking bupropion." C. "I may not notice a lifting of my mood for at least 2 weeks." D. "I should watch for increased salivation and drooling while taking bupropion."
Answer: C. "I may not notice a lifting of my mood for at least 2 weeks."
A nurse is providing teaching for a patient who has binge-eating disorder and is morbidly obese. The patient has been prescribed orlistat. Which of the following statements indicates to the nurse that the patient understands the teaching? A. "I will take my dose of orlistat every morning an hour before breakfast." B. "I will eat a no-fat diet to prevent side effects from the medication." C. "I will stop taking orlistat and call my doctor if my urine gets darker in color." D. "I will feel less hungry during meals while I am taking orlistat."
Answer: C. "I will stop taking orlistat and call my doctor if my urine gets darker in color." Rationale: Orlistat can cause severe liver damage; therefore, the client should be taught manifestations of liver damage, including dark-colored urine, light-colored stools, jaundice, anorexia, vomiting, and fatigue.
A nurse is assessing a patient who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? A. Delusions B. Neologisms C. Anhedonia D. Echopraxia
Answer: C. Anhedonia Rationale: Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.
A nurse is caring for a patient who has bipolar disorder and a new prescription for valproate. Which instruction should the nurse give the patient about the use of this medication? A. Thyroid function tests should be performed every 6 months B. A pretreatment EEG will be done C. Liver function tests must be monitored D. High serum sodium levels can cause toxic levels of valproate.
Answer: C. Liver function tests must be monitored Rationale: Pancreatitis, hepatic dysfunction, and thrombocytopenia are serious adverse effects occasionally associated with valproate. Liver function tests should be monitored periodically to check for hepatic failure.
A nurse is planning care for a newly admitted patient who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse? A. Schedule the patient for group therapy sessions B. Maintain consistent rules C. Provide frequent high-calorie snacks D. Avoid use of value judgements
Answer: C. Provide frequent high-calorie snacks Rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.
A nurse is caring for a patient who has dementia and handles anxiety by confabulating. The nurse should recognize this when the patient: A. displays compulsive and ritualistic behaviors B. reminisces about the past C. makes up stories when unable to remember actual events D. refuses to leave home to see a provider
Answer: C. makes up stories when unable to remember actual events Rationale: Confabulating is filling in gaps in memory by fabrication. A client who has dementia may do this to cover for and decrease anxiety about memory gaps.
A nurse is providing teaching for a patient who has a new prescription for clozapine. Which of the following statements indicates the patient understands the teaching? A. "This medication will help prevent seizures." B. "This medication will be administered by IM injection every 2 weeks." C. I should expect to develop ringing in my ears while taking this medication." D. "I will rise slowly from a lying position to prevent fainting while taking this medication."
Answer: D. "I will rise slowly from a lying position to prevent fainting while taking this medication." Rationale: Clozapine can cause orthostatic hypotension, especially during the first few weeks of therapy. The client should be taught to rise slowly from a lying or sitting position.
A charge nurse is preparing an educational session for a group of newly licensed nurses to review patient rights under the law. Which statement should the nurse make? A. " Information regarding patients should remain confidential until after their death." B. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." C. "As long as the patient's identity is disguised, their health information can be shared between professionals on the internet." D. "In the event a patient threatens harm to others, medications can be administered without consent."
Answer: D. "In the event a patient threatens harm to others, medications can be administered without consent." Rationale: The charge nurse should inform the participants that their primary commitment is to the client and their priority is always to advocate for and protect their health and safety. During an emergency situation, if the client is threatening harm to self or others, medications can be administered without the client's consent and without a court order.
A home health nurse is assessing an older adult patient whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? A. Increased Confusion B. Sleep disturbances C. Cluttered environment D. Inappropriate dress
Answer: D. Inappropriate dress Rationale: Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.
A nurse is caring for a patient with major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The patient reports having an improved appetite, but still feels depressed and is still having trouble sleeping. Which action should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain that antidepressants often take several weeks to be fully effective. C. Tell the patient that the provider will need to change citalopram to a different medication. D. Recommend a sleep study be done on the patient.
B. Explain that antidepressants often take several weeks to be fully effective. Explanation: SSRIs are used along with certain anticonvulsant medications in the treatment of bipolar disorder. It can take 4 to 6 weeks before therapeutic effects occur after beginning an antidepressant medication.
