Mental Health Nursing ATI Quiz 2

A nurse is providing teaching to a client who has a new prescription for alprazolam. Which of the following is the priority information the nurse should include in the teaching? A. "This medication can affect your ability to drive or handle mechanical equipment." B. "You should avoid drinking beverages that contain caffeine with this medication." C. "You should avoid taking antacids within 2 hours of taking this medication." D. "This medication should be taken with or shortly after meals."

A. "This medication can affect your ability to drive or handle mechanical equipment."

A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. Which of the following statements should the nurse make? A. "We'll assist you with making decisions." B. "Someone will work with you when you have flashbacks." C. "You'll be going through aversion therapy to help you cope." D. "The therapy will help you control your impulses."

A. "We'll assist you with making decisions." (Clients who have generalized anxiety disorder are often indecisive and dread making decision. Therefore, the nurse should reassure the client that they will receive help with making decisions.)

A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for several months. Which of the following levels should the nurse recognize as a therapeutic lithium level? A. 1.2 mEq/L B. 1.6 mEq/L C. 2.0 mEq/L D. 2.5 mEq/L

A. 1.2 mEq/L (This is within the expected reference range. Clients taking lithium should drink 6-8 glasses of water a day to maintain a normal state of hydration. Clients should also consume an adequate amount of sodium to prevent lithium toxicity.)

A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse should identify that the client is exhibiting which of the following disorders? A. Agoraphobia B. Posttraumatic stress disorder C. Panic disorder D. Obsessive-compulsive disorder

A. Agoraphobia (Fear and subsequent avoidance of places or situations from which escape might be difficult.)

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as, "Me, see, bee, tree." The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia? A. Clang association B. Echolalia C. Magical thinking D. Word salad

A. Clang association (The stringing and repeating of words together because of their rhyming sounds. A positive manifestation of schizophrenia.)

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take when dealing with the client's ritualistic behaviors? A. Plan the client's schedule to allow time to perform rituals. B. Verbalize disapproval of ritualistic behavior. C. Place the client in protective isolation. D. Increase stimuli in the client's immediate surroundings.

A. Plan the client's schedule to allow time to perform rituals. (The nurse should allot sufficient time for the client to perform rituals early in the treatment. This will help keep anxiety levels manageable and prevent the precipitation of panic anxiety.)

A nurse is assessing a newly admitted client who has generalized anxiety disorder and states, "I drink alcohol to forget the pain." The client is exhibiting a maladaptive response to which of the following defense mechanisms? A. Rationalization B. Conversion C. Projection D. Suppression

A. Rationalization is a defense mechanism by which a person covers up a real or perceived problem or weakness. This client is attempting to justify alcohol use by explaining that it helps to relieve pain. This is done to protect the client's ego and to satisfy the nurse

A nurse is caring for a client who has an obsessive-compulsive disorder. The client engages in repeated handwashing daily. Which of the following should the nurse recognize as the purpose of the client's behavior? A. Relieving anxiety B. Gaining attention C. Avoiding daily responsibilities D. Responding to auditory hallucinations

A. Relieving anxiety

A nurse on an inpatient unit is assessing a client who has claustrophobia. The nurse determines the client's condition has improved when he can perform which of the following tasks? A. Ride in an elevator. B. Attend a class where several service animals are present. C. Sit in a large room with several people he does not know. D. Go for a swim in an outdoor pool.

A. Ride in an elevator. (Claustrophobia is an intense anxiety or fear about being in an enclosed space, such as an elevator. Riding in a closed elevator is an indication that this client's condition is improving.

A nurse is caring for a client who has a severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take? A. Speak to the client in a calm voice. B. Leave the client alone to regain control. C. Encourage the client to express her feelings. D. Place the client in restraints.

A. Speak to the client in a calm voice. (The initial goal for a client who is in a state of panic is to obtain relief. The nurse should stay with the client and speak in a calm manner.)

A nurse is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective? A. The client reports techniques she uses to promote sleep. B. The client shows limited emotion when witnessing a traumatic event. C. The client asks the nurse's opinion about clothes she is wearing. D. The client avoids situations that might trigger memories of past trauma.

A. The client reports techniques she uses to promote sleep. (Clients who have PTSD often experience disrupted sleep; therefore, reporting techniques she uses to promote sleep indicates the current treatment plan is effective.)

A nurse is providing teaching to a client who has a new prescription for diazepam. Which of the following instructions should the nurse include in the teaching? A. "Expect this medication to make you feel anxious." B. "This medication can be habit-forming." C. "Take this medication on an empty stomach." D. This medication takes 2-3 weeks to reach full therapeutic effect."

B. "This medication can be habit-forming." (Diazepam is a benzodiazepine agent. All drugs in this category can cause physical dependence and are considered controlled substances.)

A nurse is providing discharge teaching for a female client who has an anxiety disorder and a new prescription for lorazepam. Which of the following instructions should the nurse include in the teaching? A. "This medication can be safely taken during pregnancy." B. "This medication must be discontinued by gradual tapering over time." C. "An extra dose of the medication can be taken at bedtime if you experience insomnia." D. "You should monitor your blood glucose levels closely while taking this medication."

B. "This medication must be discontinued by gradual tapering over time." (Rapid withdrawal from lorazepam has been associated with manifestations of withdrawal, such as anxiousness, sleeplessness, and irritability. It is discontinued by gradually tapering it off over time to avoid an adverse responses.)

A school nurse is caring for an adolescent client who has a history of a depressive episode 1 year ago. He appears withdrawn from social activities and his school performance is declining. Which of the following actions should the nurse take first? A. Initiate a structured daily schedule of activities. B. Conduct a suicide-risk assessment. C. Encourage the client to express his feelings in a journal. D. Ask teachers to monitor for other signs of depression.

B. Conduct a suicide-risk assessment.

A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited the day before. Which of the following cognitive impairments is the client demonstrating? A. Perseveration B. Confabulation C. Apraxia D. Agnosia

B. Confabulation (Filling in gaps in memory by fabrication. The client unconsciously makes up responses that are inaccurate to avoid the embarrassment of memory loss.)

A nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy? A. Setting a time limit between episodes of hand hygiene. B. Demonstrating performance of hand hygiene at scheduled times. C. Telling the client to shout "stop" each time there is an urge to perform hand hygiene. D. Instructing the client to practice muscle relaxation when experiencing the urge to perform hand hygiene.

B. Demonstrating performance of hand hygiene at scheduled times. (This is an example of modeling, which is a behavioral intervention strategy that allows the client to see the expected behaviors performed by the nurse.)

A nurse is assessing a client who has an anxiety disorder and is taking a benzodiazepine. For which of the following adverse effects should the nurse monitor the client? A. Seizures B. Dizziness C. Polyuria D. Insomnia

B. Dizziness (A common adverse effect expected in a client who has a prescription for a benzodiazepine. Other common adverse effects are drowsiness and sedation.)

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception

B. Impaired judgment (Impaired judgment occurs in clients who have dementia because they lose their ability to reason, think abstractly, and have rational thoughts.)

A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. Which of the following actions should the nurse take first? A. Identify the cause of the anxiety. B. Instruct the client to take slow, deep breaths. C. Teach the client how to use positive self-talk. D. Explain the physical manifestations of anxiety to the client.

B. Instruct the client to take slow, deep breaths.

An emergency room nurse is assessing a client who has an anxiety disorder. The client is flushed, perspiring profusely, and is experiencing palpitations. The client begins to scream, "I am going to die! This is it! I am having a heart attack!" The nurse should determine the client's level of anxiety to be which of the following? A. Moderate B. Panic C. Severe D. Mild

B. Panic (This client's manifestations indicate the panic level of anxiety and indicate manifestations of a panic disorder.)

A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect? A. Progressive deterioration of cognitive function B. Rapid fluctuation in level of consciousness C. Loss of language ability D. Absence of contributing factors to pinpoint cause of delirium

B. Rapid fluctuation in level of consciousness (A rapidly fluctuating level of consciousness is an expected finding for a client who has acute delirium.)

A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make? A. "This medication is a tricyclic antidepressant and will improve your mood." B. "This medication is an opioid antagonist that blocks the pleasurable effects of alcohol." C. "This medication is an antipsychotic that controls manifestations of schizophrenia." D. "This medication is a cholinesterase inhibitor that slows the progression of dementia."

C. "This medication is an antipsychotic that controls manifestations of schizophrenia." (Antipsychotic medications, such as chlorpromazine, are thought to act directly on the dopamine receptors in the brain to prevent the reuptake of dopamine, thereby controlling psychotic manifestations.)

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates that the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take? A. Contact the provider for a dosage increase. B. Request a repeat of the lithium level. C. Administer the medication. D. Prepare the client for gastric lavage.

C. Administer the medication. (The nurse should administer the medication because the lithium level is within the expected reference range.)

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? A. Spaghetti and meat balls, a salad, and apple pie B. Beef and vegetable stew, rice, and vanilla pudding C. Chicken nuggets, crackers with cheese sticks, and a cookie D. Broiled fish fillets, stewed tomatoes and ice cream

C. Chicken nuggets, crackers with cheese sticks, and a cookie (High calorie finger foods that can be carried and are relatively easy to manipulate.)

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first? A. Encourage the client to verbalize her feelings. B. Teach the client relaxation techniques. C. Determine the client's anxiety level. D. Role-play problem solving behaviors with the client.

C. Determine the client's anxiety level.

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

C. Drowsiness (The nurse should inform the client that drowsiness is one of the most common adverse effects of doxepin.)

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

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

A nurse is assessing a client who has been taking an antipsychotic medication for 6 years and the provider has started tapering off the dosage. The nurse should monitor the client for which of the following manifestations of tardive dyskinesia? A. Muscular weakness B. Muscle spasms C. Involuntary tongue protrusion D. Uncontrolled rolling of the eyes

C. Involuntary tongue protrusion (Tardive dyskinesia begins with mouth & facial movements and then progresses to involve other muscle groups. All clients receiving antipsychotic therapy for months to years are at risk. This adverse effect is potentially irreversible and discontinuing the drug rarely relieves these manifestations.)

The nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment? A. Perception of reality B. Ability to follow directions C. Physical needs D. Metal status

C. Physical needs (The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority.)

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

D. "I should expect to feel the full effect of my medication in 2 to 4 weeks." (The desired response from buspirone can begin within 7 to 10 days; however, it takes 2 to 4 weeks for buspirone to reach its full effect.)

A nurse is assessing a client who has been taking thioridazine for several days. The client reports hand tremors, drooling, and rigid extremities. Which of the following actions should the nurse take? A. Reassure the client that these effects are expected. B. Administer diazepam. C. Encourage deep breathing and relaxation. D. Administer benztropine.

D. Administer benztropine. (The client is experiencing extrapyramidal effects of thioridazine, which includes pseudoparkinsonism. Benztropine is a medication that counteracts these adverse effects. The nurse should notify the provider if extrapyramidal effects occur and obtain a prescription to alleviate the manifestations.)

A nurse is assessing a client who has a psychotic disorder and a new prescription for haloperidol. the client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is the client likely experiencing? A. Dystonia B. Parkinsonism C. Tardive dyskinesia D. Akathisia

D. Akathisia (Characterized by client's report of inner restlessness and by an observable behaviors such as pacing, rocking forward and backward in a chair, and constant foot tapping.)

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first? A. Teach the client strategies to decrease her hallucinations. B. Identify if the client is on antipsychotic medications. C. Distract the client from the hallucination. D. Explore what the voices are saying to the client.

D. Explore what the voices are saying to the client.

A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Bradycardia B. Increased somnolence C. Slurred speech D. Headache

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

The nurse in the emergency department is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect? A. Pinpoint pupils B. Drowsiness C. Nystagmus D. Hypervigilance

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

A nurse is assessing a client who has schizophrenia. The client states, "I need to get my gummamoshu from by my house." The nurse recognizes this statement as an example of which of the following? A. Flight of ideas B. Echolalia C. Perseveration D. Neologism

D. Neologism (An invented word which has no meaning to those around him.)

A nurse in a mental health clinic is assessing a client who has a history of mania. Which of the following findings indicates that the client is experiencing a relapse? A. Weight gain B. Ritualistic behavior C. Anhedonia D. Pressured speech

D. Pressured speech (Pressured speech is an indication of a relapse in a client who has mania.)

A nurse is providing teaching to a client who has a new prescription for phenelzine. The nurse should teach the client that which of the following over-the-counter medications can cause a hypertensive crisis when taken concurrently with phenelzine? A. Acetaminophen B. Ranitidine C. Naproxen D. Pseudophedrine

D. Pseudophedrine (Pseudophedrine interacts with MAOI medications and is therefore contraindicated. Ingesting products containing ephedrine along with phenelzine can precipitate a hypertensive crisis.)

A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors should the nurse identify as increasing the client's risk for depression. A. The client is an only child. B. The client lives in an urban setting. C. The client is married. D. The client is female.

D. The client is female. (The nurse should identify female gender as a primary risk factor for depression. The incidence of depressive disorders is greater in women than in men by almost 2 to 1.)

A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the client's provider immediately? A. Dry mouth B. Constipation C. Drowsiness D. Urinary retention

D. Urinary retention (Can lead to bladder infection and, ultimately, loss of bladder tone.)