Mental Health Final ATI

A nurse is teaching a client who wants to stop smoking by using nicotine lozenges. Which of the following statements should the nurse make?

"Limit your use to no more than 20 lozenges per day." The nurse should instruct the client that users should consume no more than 5 lozenges within 6 hours and should not have more than 20 lozenges per day.

A nurse is teaching a client who has anxiety and a new prescription for buspirone. Which of the following pieces of information should the nurse include in the teaching?

"Avoid consuming grapefruit juice when taking this medication." The nurse should instruct the client to avoid drinking grapefruit juice when taking buspirone because it can cause levels of the medication to increase. Elevated levels can cause drowsiness and subjective effects such as dysphoria.

A nurse is teaching a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse take?

"Eat a light snack containing carbohydrates before bedtime." A light snack consisting of a carbohydrate based food or milk can help promote sleep when ingested before bedtime. Consuming heavy meals just before sleeping can promote insomnia.

A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching?

"I am likely to gain weight while taking lithium." The nurse should instruct the client to eat a low-calorie diet while taking lithium because this medication can cause weight gain.

A nurse is providing teaching to the guardian of a school-aged child who has ADHD and a new prescription for clonidine. Which of the following statements by the guardian indicates an understanding of the teaching?

"I can expect my child to be drowsy while taking this medication." The nurse should instruct the guardian that clonidine can cause adverse effects like somnolence, fatigue, and hypotension.

A nurse is assessing a client who has major depressive disorder for suicide risk factors and protective factors. Which of the following client statements should the nurse identify as a protective factor that decreases the client's risk for suicide?

"I consider myself a good problem-solver." The ability to problem-solving and to think critically is a protective factor against suicide. Feelings of low self-esteem or hopelessness are risk factors for suicide.

A new patient beginning an alcohol rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Which responses by the nurse will be most therapeutic? (Select all that apply).

"Social drinkers have one or two drinks, once or twice a week." "You describe drinking steadily throughout the day and evening." The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? (Select all that apply).

"Tell me how you discipline your children." "How do you stop your baby from crying." "Caring for four small children must be difficult." An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide?

"There's no point in living any longer." The nurse should identify this client comment as an overt statement about the client's risk of suicide. The nurse should assess the client's suicidal ideation further and implement interventions to promote safety.

A nurse is teaching a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include?

"You can expect to wake up about 15 minutes after the procedure." A client who undergoes ECT usually wakes up about 15 minutes after the procedure and can be disoriented for several hours after.

A nurse is providing teaching to the parent of a school-aged child who has ADHD and a new prescription for methylphenidate IR. Which of the following pieces of information should the nurse provide?

"Your child's growth might slow while using this medication." The nurse should instruct the parent that an adverse effect of methylphenidate is growth suppression related to the appetite suppression associated with the medication. Administering the medication with or after meals will help protect the child's appetite.

A nurse is assessing a client who has binge-eating disorder. Which of the following findings should the nurse expect?

Abdominal pain The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain due to the gastrointestinal dilation that results from eating excessive volumes of food.

Which statement about paraphilic disorders is accurate?

Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon. Paraphilic disorders are uncommon; however, because persons with these disorders repeatedly enact behavior associated with their disorders, paraphilic acts are relatively common. The majority of victims of pedophiles are males om early adolescence; those pedophiles who prefer females usually prefer prepubescent children. Some persons with paraphilic disorders experience shame and are at higher risk for suicide due to stigma, shame, and embarrassment. Biological and psychological drives underlying paraphilic behavior can be very strong and often are not controllable by willpower alone. Persons with paraphilic disorders have difficulty controlling their behavior, even when very motivated to do so.

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood?

Affect flat, mood depressed Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first?

Assertive community treatment Evidence-based practice indicates the nurse should first refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for the client who has bipolar disorder with rapid cycling as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so inpatient hospitalizations can be avoided.

A nurse is caring for a client who has chronic alcohol use disorder and claims that her family is exaggerating the problem. The nurse should identify this behavior as which of the following defense mechanisms?

Denial The nurse should identify denial as actions and statements by the client that do not acknowledge the reality of a situation.

A nurse is caring for a client who has alcohol use disorder. Following alcohol withdrawal, which of the following medications should the nurse expect to administer to the client during maintenance?

Disulfiram The nurse should expect to administer disulfiram as a deterrent to prevent future alcohol use. The nurse must ensure the client has not had any alcohol intake for at least 12 hours prior to administration.

A child diagnosed with ADHD had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? The child

Engages in cooperative play with other children The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.

A nurse is preparing to meet a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship?

Facilitate a change in the client's behavior The nurse should facilitate a change in the client's behavior during the working phase of the therapeutic relationship.

A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

Headache A headache is an expected finding in a client who is experiencing alcohol withdrawal. This can occur 4 to 12 hours following the cessation of alcohol use. Other findings include hand tremors, nausea, vomiting, sweating, depression, or irritability.

A nurse in an emergency department is assessing a client who reports recent cocaine use. Which of the following manifestations should the nurse expect?

Hypertension Cocaine is a central nervous system stimulant. Therefore, hypertension is an expected finding in a client who has recently used cocaine.

A nurse in the emergency department is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?

Hypervigilance Paranoid behavior is an expected finding for a client who has cocaine intoxication.

Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply).

Impaired level of consciousness Disorientation to place, time Wandering attention Disorientation to place and time is an expected finding. Orientation to person (self) usually remain intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply).

Keep a cell phone fully charged Have the phone number for the nearest shelter Secure a supply of current medications for self and children. Assemble birth certificates, social security cards, and licenses. Determine a code word to signal children when it is time to leave The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumberstone and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

A nurse is determining a client's total score for the Alcohol Use Disorders. Identification test (AUDIT) by assigning a score of 0 to 4 for each answer. For which of the following self-reported findings should the nurse assign the client a score of 4?

Last month, the provider suggested the client should reduce alcohol intake. When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 4 if the client indicates that a friend, relative, or healthcare provider has recommended decreasing alcohol consumption at least once during the last 12 months.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply).

Limit credit card access Provide a structured environment Supervise medication administration Monitor the patient's sleep patterns A patient who with hypomania is expansive, grandiose, and labile; uses poor judgment; speaks inappropriately; and is over-stimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. The family should supervise medication administration to prevent deterioration to a full manic episode and because the patient is at risk to omit medications.

A nurse is an acute substance disorder unit is assessing a client who received treatment in the emergency department for a heroin overdose. Which of the following findings should the nurse anticipate during heroin withdrawal?

Muscle aches The nurse should expect the client to have muscle aches during heroin withdrawal. The nurse should expect manifestations of withdrawal to begin within 6 to 8 hours following the last dose of heroin.

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8 F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action.

Neuroleptic malignant syndrome; notify health care provider stat. Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome; a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? (Select all that apply).

Stating the expectation that the patient will stay in control Offering to provide the patient with medication to help Speaking in a firm by calm voice Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

A nurse in a provider's office is reviewing the medical history of a client who asks about the use of varenicline for smoking cessation. Which of the following items in the client's medical history indicates a precaution for the use of varenicline?

The client has a history of depression The nurse should recognize that varenicline can cause mood changes and thoughts of suicide. Precautions should be taken when prescribing this medication to the clients who have a history of psychiatric disease such as depression.

A nurse is assessing a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache, and extreme thirst. The nurse should identify that which of the following situations is occuring?

The client is experiencing mild acetaldehyde syndrome The nurse should recognize that these manifestations are an indication of acetaldehyde syndrome, which occurs when alcohol consumption is combined with disulfiram use. The client's current manifestations represent the mild form of acetaldehyde syndrome that can occur by consuming as little as 7 mL (0.2 oz) of alcohol.

Which nursing diagnoses are most applicable for a patient diagnosed with severe late stage Alzheimer's disease? (Select all that apply)

Urinary continence Disturbed sleep pattern Risk for caregiver role strain The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

A nurse is assessing a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication?

Xerostomia Buspirone, a benzodiazepine, can cause xerostomia (dry mouth). Other adverse effects include headaches, nausea, and insomnia.