NR 326 Exam #3

A nurse caring for a client diagnosis with AD with script for donepezil. Med teaching includes:

"You should take this medication before going to bed."

A nurse is planning care to promote a safe and therapeutic environment for a client who has severe cognitive decline due to Alzheimer's disease. ALTERATION IN HEALTH (DIAGNOSIS):

-Alzheimer's disease is a subtype of neurocognitive disorder that is neurodegenerative, resulting in the gradual impairment of cognitive function. -A client who has severe cognitive decline has memory difficulties, loss of awareness to recent events and surroundings, inability to recall personal history, personality changes, wandering behavior, the need for assistance with ADLs, disruption of sleep/wake cycle, and violent tendencies.

A nurse is planning care to promote a safe and therapeutic environment for a client who has severe cognitive decline due to Alzheimer's disease. NURSING CARE: Identify five nursing actions.

-Assign a room close to the nurses' station -provide a room with a low level of visual and auditory stimuli. -provide for a well‐lit environment, minimizing contrasts and shadows. -Have the client sit in a room with windows to help with time orientation. -Have the client wear an identification bracelet. Use monitors and bed alarm devices as needed. -Monitor the client's level of comfort. -provide compensatory memory aids (clocks, calendars, photographs, memorabilia, seasonal decorations, and familiar objects). Reorient as necessary. -provide eyeglasses and assistive hearing devices as needed. -Keep a consistent daily routine. -Maintain consistent caregivers. -Ensure adequate food and fluid intake. -Allow for safe pacing and wandering. -Cover or remove mirrors to decrease fear and agitation.

Nursing considerations for conventional antipsychotics (haloperidol) include which of the following?

Contraindicated in older adults with dementia; Use cautiously in clients with seizure disorders; Contraindicated in clients with severe hypotension.

Which of the following nursing care is best for a client with a diagnosis of anorexia nervosa with binge-eating and purging behavior?

Implement one-to-one observation during meal time.

A home care RN has a client with AD. Nursing interventions to decrease injury includes which of the following?

Install extra locks at the top of exit doors; Stairs should have adequate lighting to reduce the risk for falls; Place the client's mattress on the floor.

A nurse is caring for a client who has anorexia nervosa of the restricting type. The client refuses to eat and exhibits severe anxiety when food is offered. The nurse plans to use desensitization as a behavioral therapy. OUTCOMES/EVALUATION

The client will effectively use relaxation techniques to suppress the anxiety response during meal times.

Borderline personality disorder is characterized by which of the following?

Unstable relationships; feeling abandoned; cutting, self-harm

CIWA is a screening tool for which condition and what score would indicate medical intervention?

Withdrawal from alcohol, 11+

A client with psychosis stares at the ceiling, mumbling. What is the nurse's priority action response?

"What do you see on the ceiling?"

Clonidine for the treatment of opioid use: which shows client understanding?

"While taking this medication, I should keep a pack of sugarless gum."

A nurse is caring for a client who has cocaine use disorder and is experiencing severe effects of intoxication. INTERPROFESSIONAL CARE: Describe two forms of nonpharmacological therapy.

-Cognitive behavioral therapies decrease anxiety and promote a change in behavior. -Acceptance and commitment therapy promotes acceptance of the client and promotes a commitment to change. -Relapse prevention therapy assists clients in identifying relapse and promotes self‐control. -Group therapy allows clients who have similar diagnoses to work together toward recovery. -Family therapy allows the client and family members to work together toward recovery. -Narcotics Anonymous provides a 12‐step program to promote recovery and abstinence from future substance use.

A nurse is caring for a client who has cocaine use disorder and is experiencing severe effects of intoxication. EXPECTED FINDINGS: Identify three expected findings.

-Objective: Seizures, extreme fever, tachycardia, hypertension -Subjective: Hallucinations, chest pain

A nurse is caring for a client who has anorexia nervosa of the restricting type. The client refuses to eat and exhibits severe anxiety when food is offered. The nurse plans to use desensitization as a behavioral therapy. NURSING INTERVENTIONS: Identify at least two.

-Teach the client relaxation techniques. -Gradually expose the client to food starting with small amounts of a food. -Stay with the client during meals to assist with relaxation. -Reward the client for food intake. -Use a positive approach to communicate the procedure and expectations to the client.

A nurse is caring for a client who has cocaine use disorder and is experiencing severe effects of intoxication. CLIENT EDUCATION: Identify two client outcomes.

-The client will verbalize coping strategies to use in times of stress. -The client will remain substance‐free. -The client will remain free from injury. -The client will attend a 12‐step program regularly.

A nurse is caring for a client who has cocaine use disorder and is experiencing severe effects of intoxication. NURSING CARE: Describe two nursing interventions.

-perform a nursing self‐assessment. -Maintain a safe environment. -Implement seizure precautions. -Orient the client to time, place, and person. -Create a low‐stimulation environment. -Monitor the client's vital signs and neurologic status.

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make? A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable." C. "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment." D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"

A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." Rationale: This statement is an example of clarification and promotes further discussion, which is a therapeutic communication technique.

A nurse is making a home visit to a client whois in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file. B. Instruct the client's partner to offer finger foods to increase oral intake. C. provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

A. A power of attorney document does not address the client's care or the concerns of the caregiver. B. Clients in late‐stage Alzheimer's disease are at risk for choking and are unable to eat without assistance. Offering finger foods is not an appropriate action. C. CORRECT: providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiving responsibilities. D. placement of an enteral feeding tube is appropriate only with a prescription from the provider following a discussion that includes the provider, nurse, client's partner, and possibly social services and additional family members.

A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior.

A. Address the client's current needs related to the possible hallucination rather than stop the interview. B. CORRECT: Ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury. C. Avoid agreeing with the client, which can promote psychotic thinking. D. Address the client's current needs related to the possible hallucination rather than ignoring the change in behavior.

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply.) A. Amenorrhea B. Hypokalemia C. Yellowing of the skin D. Slightly elevated body weight E. Presence of lanugo on the face

A. Amenorrhea is an expected finding of anorexia nervosa rather than bulimia nervosa. B. CORRECT: Hypokalemia is an expected finding of purging‐type bulimia nervosa. C. Yellowing of the skin is an expected finding in anorexia nervosa rather than bulimia nervosa. D. CORRECT: Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher. E. Lanugo is an expected finding of anorexia nervosa rather than bulimia nervosa.

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

A. An expected finding of alcohol withdrawal is tachycardia rather than bradycardia. B. CORRECT: Fine tremors of both hands is an expected finding of alcohol withdrawal. C. An expected finding of alcohol withdrawal is hypertension rather than hypotension. D. CORRECT: Vomiting is an expected finding of alcohol withdrawal. E. CORRECT: Restlessness is an expected finding of alcohol withdrawal.

A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the teaching? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."

A. Antipsychotic medications are considered a long‐term treatment for schizophrenia. Discontinuing the medication can result in an exacerbation of manifestations. B. Drowsiness is a common adverse effect of antipsychotic medications. However, it is not appropriate to discontinue the medication. C. CORRECT: Antipsychotic medications (iloperidone) have a high risk for significant weight gain. D. Antipsychotic medications are not considered addictive, and it is not necessary to titrate iloperidone when discontinuing treatment.

A nurse is assisting with a court‐ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Demonstrates extreme anxiety when placed in a social situation B. Often engages in magical thinking C. Attempts to convince other clients to relinquish their belongings D. Becomes agitated if personal area is not neat and orderly E. Blames others for personal past and current problems

A. Anxiety in social situations is an expected finding of clients who have avoidant personality disorder. B. Magical thinking and odd beliefs are findings observed in clients who have schizotypal personality disorder. C. CORRECT: Exploitation and manipulation of others is an expected finding of antisocial personality disorder. D. perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive‐compulsive personality disorder. E. CORRECT: Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder.

Which of the following findings should the nurse document as positive symptoms of schizophrenia ? (SATA) A. Auditory hallucination B. Flat affect C. Use of clang association D. Lack of motivation

A. Auditory hallucinations C. Use of clang association

A nurse in a long‐term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

A. Avoid statements that can be interpreted as argumentative or demeaning. B. Use positive, rather than negative, statements. C. Using a "why" question can promote a defensive reaction and does not reinforce reality. D. CORRECT: It is appropriate to introduce oneself with each new interaction and to promote reality in a calm, reassuring manner.

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following medications? A. Chlorpromazine B. Thiothixene C. Risperidone D. Haloperidol

A. First‐generation antipsychotics (chlorpromazine) are used mainly to control positive, rather than negative, symptoms of schizophrenia. B. First‐generation antipsychotics (thiothixene) are used mainly to control positive symptoms of schizophrenia. C. CORRECT: Second‐generation antipsychotics (risperidone) are effective in treating negative symptoms of schizophrenia (lack of grooming and flat affect). D. First‐generation antipsychotics (haloperidol) are used mainly to control positive symptoms of schizophrenia.

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply.) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"

A. CORRECT: A nursing history of a client who has anorexia nervosa should include an assessment of family and interpersonal relationships. B. Asking a "why" question promotes a defensive client response and is therefore nontherapeutic. C. CORRECT: A nursing history of a client who has anorexia nervosa should include an assessment of the client's current eating habits. D. This question promotes cognitive distortion, places the focus on weight, and implies that the client's current appearance is not acceptable. E. CORRECT: A nursing history of a client who has anorexia nervosa should include an assessment of the client's perception of the issue.

A nurse is caring for a client who has substance‐induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (Select all that apply.) A. "When did you start hearing these things?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?" E. "Why are the voices talking to only you?"

A. CORRECT: Ask the client directly about the hallucination. B. Do not argue with the client's view of the situation. C. CORRECT: Focus on the client's feelings rather than agreeing with the client's hallucination. D. CORRECT: Assess for command hallucinations and the client's risk for injury to self or others. E. Avoid asking a "why" question, which is non-therapeutic and can promote a defensive client response.

A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

A. CORRECT: Carbamazepine is used during withdrawal to decrease the risk for seizures. B. Carbamazepine is used to promote safe withdrawal rather than to decrease cravings for alcohol. C. Clonidine or propranolol is used during withdrawal to depress the autonomic response and its effect on blood pressure. D. Carbamazepine is used to promote safe withdrawal rather than abstinence.

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

A. CORRECT: Clients who have avoidant personality disorder often have a fear of abandonment.This type of statement is expected. B. This statement indicates manipulation, which is expected from a client who has antisocial personality disorder. C. This statement indicates a need for admiration, which is expected from a client who has narcissistic personality disorder. D. This statement indicates a risk for self‐injury, which is expected from a client who has borderline personality disorder.

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply.) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

A. CORRECT: Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types. B. Clients who have schizotypal personality disorder can display magical thinking or delusions. However, this is not associated with all personality disorder types. C. CORRECT: Maladaptive response to stress is a personality characteristic that can be seen in clients who are experiencing personality disorders. D. Clients who have narcissistic personality disorder can display grandiose thinking. However, this is not associated with all personality disorder types. E. CORRECT: Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types.

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect

A. CORRECT: Hallucinations are an example of a positive symptom. B. Lack of motivation, or avolition, is an example of a negative symptom. C. CORRECT: Alterations in speech are an example of a positive symptom. D. CORRECT: Delusions are an example of a positive symptom. E. CORRECT: Bizarre motor movements are an example of a positive symptom. F. Flat affect is an example of a negative symptom.

A nurse is discussing the use of methadone witha newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply.) A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be prescribed and dispensed by an approved treatment center."

A. CORRECT: Methadone is an oral opioid agonist that replaces the opioid to which the client has a physical dependence. B. CORRECT: Methadone administration prevents abstinence syndrome from occurring. C. CORRECT: Methadone substitution is used for both opioid withdrawal and long‐term maintenance. D. Disulfiram, rather than methadone, places the client at risk for acetaldehyde syndrome if the client consumes alcohol while taking the medication. E. CORRECT: Due to the risk for physical dependence, methadone is required to be prescribed and dispensed by an approved treatment center.

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (Select all that apply.) A. Olanzapine B. Quetiapine C. Aripiprazole D. Clozapine E. Asenapine

A. CORRECT: Olanzapine is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases therisk for agitation associated with an injection. B. Quetiapine is available only in tablets or extended‐release tablets and will therefore not address the current concerns with medication administration. C. CORRECT: Aripiprazole is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases therisk for agitation associated with an injection. D. CORRECT: Clozapine is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases therisk for agitation associated with an injection. E. CORRECT: Asenapine is available in a sublingual tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases the risk for agitation associated with an injection.

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

A. CORRECT: This statement reflects the cognitive distortion of catastrophizing because the client's perception of their appearance or situation is much worse than their current condition. B. This statement reflects the cognitive distortion of personalization rather than catastrophizing. C. This statement reflects the cognitive distortion of overgeneralization rather than catastrophizing. D. This statement reflects a perception of distorted body image commonly experienced by the client who has anorexia nervosa. However, it is not an example of catastrophizing.

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? A. Install extra locks at the top of exit doors. B. place rugs over electrical cords. put cleaning supplies on the top of a shelf. C. place the client's mattress on the floor. D. Install light fixtures above stairs.

A. CORRECT: placing door locks up high where they are difficult to reach can prevent exiting the home and wandering outside. B. Rugs create a fall risk hazard and should be removed. Electrical cords should be secured to baseboards rather than covered. C. Cleaning supplies should be placed in locked cupboards. Marking the supplies with colored tape does not prevent the client's access to hazardous materials. D. CORRECT: placing the client's mattress on the floor reduces the risk for falls out of bed. E. CORRECT: Stairs should have adequate lighting to reduce the risk for falls.

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first‐generation antipsychotics? (Select all that apply.) A. Auditory hallucinations B. Withdrawal from social situations C. Delusions of grandeur D. Severe agitation E. Anhedonia

A. CORRECT: positive symptoms of schizophrenia (auditory hallucinations) are effectively treated with first‐generation antipsychotics. B. First‐generation antipsychotics have minimal effectiveness with negative symptoms of schizophrenia (social withdrawal). C. CORRECT: positive symptoms of schizophrenia (delusions of grandeur) are effectively treated with first‐generation antipsychotics. D. CORRECT: positive symptoms of schizophrenia (severe agitation) are effectively treated with first‐generation antipsychotics. E. First‐generation antipsychotics have minimal effectiveness

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide B. Bupropion C. Disulfiram D. Carbamazepine

A. Chlordiazepoxide is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol. B. Bupropion is indicated for nicotine withdrawal rather than to maintain abstinence from alcohol. C. CORRECT: The nurse should expect to administer disulfiram to help the client maintain abstinence from alcohol. D. Carbamazepine is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol.

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates an understanding of the teaching? (Select all that apply.) A. "We need to understand that our sibling is responsible for their disorder." B. "Eliminating codependent behavior will promote recovery." C. "Our sibling should participate in an Al‐Anon group to assist with recovery." D. "The primary goal of treatment is abstinence from substance use." E. "Our sibling needs to discuss personal feelings about substance use to help with recovery."

A. Clients are not responsible for their disease but are responsible for their recovery. B. CORRECT: Families should be aware of codependent behavior (enabling) that can promote substance use rather than recovery. C. Al‐Anon is a recovery group for the family of a client, rather than the client who has a substance use disorder. D. CORRECT: Abstinence is the primary treatment goal for a client who has a substance use disorder. E. CORRECT: Clients must acknowledge their feelings about substance use as part of a substance use recovery program.

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over‐the‐counter acetaminophen while on donepezil." B. "You should take this medication before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

A. Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding. B. CORRECT: Clients should take donepezil at the end of the day, just before going to bed, with or without food. C. Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease, prior to treatment. D. Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction. However, the client should not abruptly stop the medication without consulting a provider.

A nurse is evaluating a client's understanding of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching? A. "Taking this medication will help reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medicine." D. "Each dose of this medication should be placed under my tongue to dissolve."

A. Clonidine is useful during opioid withdrawal. However, it does not reduce cravings. B. CORRECT: Clonidine commonly causes clients to experience dry mouth. Chewing sugarless gum is an effective method to address this adverse effect. C. Clonidine reduces, rather than causes, diarrhea and other withdrawal manifestations related to autonomic hyperactivity. D. Buprenorphine, rather than clonidine, is administered sublingually.

Nursing care for client diagnosed with an eating disorder include which of the following? (SATA) A. Consistency with care among staff B. Provide a flexible, unstructured milieu environment & therapy C. Encourage client decision making and participation in the plan of care D. Consult with registered dietician for meal planning

A. Consistency with care among staff C. Encourage client decision making and participation in the plan of care D. Consult with registered dietician for meal planning

Nursing considerations for conventional antipsychotics (ex: haloperidol) include which of the following? A. Contraindicated in older adults with dementia B. Use cautiously in clients with seizure disorders C. Use cautiously in clients with eating disorders D. Contraindicated in clients with severe hypotension

A. Contraindicated in older adults with dementia B. Use cautiously in clients with seizure disorders D. Contraindicated in clients with severe hypotension

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EpS)? (Select all that apply.) A. Decreased level of consciousness B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing

A. Decreased level of consciousness is an indication of neuroleptic malignant syndrome rather than an EpS. B. CORRECT: Drooling is an indication of pseudoparkinsonism, which is an EpS. C. CORRECT: Involuntary arm movements are an indication of tardive dyskinesia, which is an EpS. D. Urinary retention is an anticholinergic effect rather than an EpS. E. CORRECT: Continual pacing is an indication of akathisia, which is an EpS.

The nurse knows that which of the following are true about the therapeutic use of Aripiprazole? (SATA) A. Decreased risk of EPSs or tardive dyskinesia B. Treats both Negative & Positive Sx C. Risk for fatal agranulocytosis D. Lower risk for weight gain

A. Decreased risk of EPSs or tardive dyskinesia B. Treats both Negative & Positive Sx D. Lower risk for weight gain

A nurse is planning discharge for a client who has a co-occurring borderline personality disorder. Which of the following interventions should be included for this client? A. Dialectical behavior therapy B. Behavioral contract C. Bibliotherapy D. Safety plan

A. Dialectical behavior therapy Rationale: Dialectical behavior therapy is appropriate for the treatment of clients with borderline personality disorder and is often a part of the discharge plan.

The nurse planning on discharge of the client with Neurocognitive Disorder who was admitted for an acute exacerbation will include which of the following caregiver education? A. Educate the caregivers on installing locks that cannot be easily opened and mark step edges with colored tape. B. Educate the caregivers on allowing the client to wander to increase comfort and mark the doors that the client is allowed to enter. C. Educate the caregivers on administering the client's medication with applesauce and allow the client to wander within safe distance from the home. D. Educate the caregivers on allowing the client to drive safe distances close to home and increase self-esteem by providing a calm environment.

A. Educate the caregivers on installing locks that cannot be easily opened and mark step edges with colored tape.

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit. B. Initiate one‐to‐one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

A. Encourage the client to participate in group therapy to assist with reality testing and to increase coping skills. However there is another action to take first. B. CORRECT: A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one‐to‐one observationis the first action the nurse should take. C. Attempt to focus the client on reality. However, there is another action to take first. D. Notify the provider of the client's hallucination. However, there is another action to take first.

The nurse will monitor signs and symptoms of serotonin syndrome which includes which of the following? A. Fever, hallucinations hyperreflexia B. Fever, delusions, muscle rigidity C. Fever, constipation, hyperrefleia, D. Fever, tremors, muscle rigidity

A. Fever, hallucinations hyperreflexia

Clients w/co-occurring personality disorders often have which of the following risk factors? (SATA) A. Hx of SUD; violent or non-violent crimes B. Traumatic car accidents with CHI C. Hx of stable living conditions with poor relationships D. Childhood abuse or trauma

A. Hx of SUD; violent or non-violent crimes D. Childhood abuse or trauma

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long‐term abstinence from alcohol? (Select all that apply.) A. Lorazepam B. Diazepam C. Disulfiram D. Naltrexone E. Acamprosate

A. Lorazepam is prescribed for short‐term use during withdrawal. B. Diazepam is prescribed for short‐term use during withdrawal. C. CORRECT: Disulfiram promotes abstinence through aversion therapy. D. CORRECT: Naltrexone promotes abstinence by suppressing the craving and pleasurable effects of alcohol. E. CORRECT: Acamprosate decreases the unpleasant effects resulting from abstinence.

A nurse is caring for a client admitted for complications related to an eating disorder. Which of the following nursing actions need to be included during complications such as re-feeding syndrome when caring for a client with an eating disorder? A. Monitor electrolytes, cardiac dysrhythmias, consult with nutritional support services. B. Monitor gastrointestinal syndrome, electrolytes, consult with psychiatric services. C. Monitor hypokalemia, anxiety, consult with nutritional support services. D. Monitor hallucinations, fluid and electrolytes, consult with nutritional support services.

A. Monitor electrolytes, cardiac dysrhythmias, consult with nutritional support services.

Nursing considerations for Haloperidol include which of the following? (SATA) A. Monitor for psuedoparkinsonism and anticholinergic adverse effects B. Monitor for mood changes and serotonin syndrome C. Monitor for severe hypertension and hyperactivity D. Monitor for agranulocytosis and EPS

A. Monitor for psuedoparkinsonism and anticholinergic adverse effects D. Monitor for agranulocytosis and EPS

Nursing considerations for Risperidone include which of the following? (SATA) A. Obtain baseline fasting blood glucose B. Monitor cholesterol & triglycerides C. Hold medication for hypotension D. Monitor for Pseudoparkinsonism

A. Obtain baseline fasting blood glucose B. Monitor cholesterol & triglycerides C. Hold medication for hypotension

Nursing actions for Risperidone administration (SATA) A. Obtain baseline fasting blood glucose, cholesterol, triglycerides B. Monitor weight gain, urinary retention, hypotension C. Do not give to patients with dementia D. Do not give to patients with COPD

A. Obtain baseline fasting blood glucose, cholesterol, triglycerides B. Monitor weight gain, urinary retention, hypotension C. Do not give to patients with dementia

A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? A. Occupational therapist B. Psychiatric social worker C. Recreational therapist D. Psychiatric clinical nurse specialist

A. Occupational therapist Rationale: An occupational therapist's primary focus is client's achieving independence with ADLs.

A nurse is caring for an older adult client who is recovering from total hip surgery. The client has a history of Depression and Dementia. Which of the following symptom manifestation is the highest priority for nursing action? A. Onset of sudden hypoactive consciousness with apathy and inattentiveness B. Onset of occasional confusion with gradual restlessness and agitation C. Onset of personality changes with apraxia and ataxia D. Onset of confusion with agnosia and loss of executive functioning

A. Onset of sudden hypoactive consciousness with apathy and inattentiveness

A nurse in an acute mental health facility is creating a plan of care for a new client who has a co-occurring histrionic personality disorder. Which of the following is the priority intervention for the nurse to make? A. Promote appropriate behavior during group therapy sessions. B. Encourage client input in the treatment plan. C. Communicate with the client using concrete language. D. Demonstrate assertive behavior.

A. Promote appropriate behavior during group therapy sessions. Rationale: Managing the client's behavior within the group is the priority intervention for the client who has histrionic personality disorder because these clients display extreme attention-seeking behaviors and are often impulsive, which can be extremely disruptive in a group setting with other members.

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit‐setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

A. Rather than establishing a schedule, the nurse should ask for the client's input and offer realistic choices to promote the client's sense of control. B. Avoid trying to increase socialization for a client who has a schizoid personality disorder. C. CORRECT: When caring for a client who has a personality disorder, limit‐setting is appropriate to help prevent client manipulation. D. Implement assertiveness training for clients who have dependent and histrionic personality disorders.

A nurse is caring for a client who has border line personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!"The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification

A. Regression refers to resorting to an earlier way of functioning (having a temper tantrum). B. CORRECT: Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time. C. Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts (buying a gift for a spouse after having an extramarital affair). D. In identification, the person imitates the behavior of someone admired or feared.

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place, and person. B. Offer fluids and nourishing diet as tolerated. C. Implement seizure precautions. D. Encourage participation in group therapy sessions.

A. Reorienting the client is an appropriate intervention. However, it is not the priority. B. providing hydration and nourishment is an appropriate intervention. However, it is not the priority. C. CORRECT: The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention. D. Encouraging participation in therapy is an appropriate intervention. However, it is not the priority.

A nurse is planning a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect. B. Older adults commonly use rationalization to cope with a substance use disorder. C. Older adults are at an increased risk for substance use following retirement. D. Older adults develop substance use to mask manifestations of dementia.

A. Requiring higher doses of a substance to achieve a desired effect is a result of the length and severity of substance use rather than age. B. Denial, rather than rationalization, is a defense mechanism commonly used by substance users of all ages. C. CORRECT: Retirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use. D. Substance use in the older adult can result in manifestations of dementia.

A nurse is planning care for a client who has anorexia nervosa with binge‐eating and purging behavior. Which of the following actions should the nurse include in the client's plan of care? A. Allow the client to select preferred meal times. B. Establish consequences for purging behavior. C. Provide the client with a high‐fat diet at the start of treatment. D. Implement one‐to‐one observation during meal times.

A. provide a highly structured milieu, including meal times, for the client requiring acute care for the treatment of anorexia nervosa. B. Use a positive approach to client care that includes rewards rather than consequences. C. Limit high‐fat and gas‐producing foods at the start of treatment. D. CORRECT: Closely monitor the client during and after meals to prevent purging.

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors? A. The client has a co-occurring borderline personality disorder. B. The client has a parent who has dependent personality disorder. C. The client has a history of bulimia nervosa. D. The client has a diagnosis of anti-social personality disorder.

A. The client has a co-occurring borderline personality disorder. Rationale: A diagnosis of borderline personality disorder is associated with an increased risk for self-harm.

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching? A. Chew the gum for no more than 10 min. B. Rinse out the mouth immediately before chewing the gum. C. Avoid eating 15 min prior to chewing the gum. D. Use of the gum is limited to 90 days.

A. The client should chew the gum slowly and intermittently over 30 min. B. The client should avoid drinking 15 min prior to chewing the gum. C. CORRECT: The client should avoid eating or drinking 15 min prior to and while chewing the gum. D. Use of nicotine gum is not recommended for longer than 6 months.

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

A. The client who has delirium can experience memory loss with sudden rather than gradual onset. B. CORRECT: The client who has delirium can experience rapid personality changes. C. CORRECT: The client who has delirium can have perceptual disturbances (hallucinations and illusions). D. The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate. E. CORRECT: The client who has delirium commonly exhibits restlessness and agitation.

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

A. This comment indicates the client is experiencing delusions of grandeur. B. CORRECT: This comment indicates the client is experiencing a loss of identity or depersonalization. C. This comment indicates the client is experiencing a tactile hallucination. D. This comment indicates the client is experiencing thought withdrawal.

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

A. This statement minimizes and generalizes the client's concern and is therefore a nontherapeutic response. B. This statement minimizes the client's concern and is therefore a nontherapeutic response. C. CORRECT: This statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self‐esteem and self‐image. D. This statement minimizes the client's concern and is therefore a nontherapeutic response.

Borderline Personality Disorder is characterized by which of the following? (SATA) A. Unstable relationships; feeling abandoned B. Cutting and self-harm C. Lack of empathy; straining most relationships D. Social inhibition; perfectionism

A. Unstable relationships; feeling abandoned B. Cutting and self-harm

Negative symptoms of Schizophrenia include which of the following? (SATA) A. flat affect B. avolition C. anergia D. agnosia

A. flat affect B. avolition C. anergia

Common laboratory abnormalities associated with anorexia and bulimia:

Anemia or leukopenia; possible metabolic alkalosis or metabolic acidosis; possible electrolyte imbalance.

Which of these personality disorders may include a history of conduct disorder diagnosed before the age of 15?

Antisocial PD

Expected findings for a client with NCD include which of the following?

Aphasia, Agnosia, Apraxia

A client has difficulty swallowing, increasing agitation with injectable Ziprasidone. Other alternative meds include:

Aripiprazole; Clozapine, Olanzapine

Which of the following findings should the nurse document as positive symptoms of schizophrenia?

Auditory hallucination and Use of clang association.

Which following nursing care is best for a client with a dx of anorexia nervosa with binge‑eating and purging behavior? A. Provide the client with a high‑fat diet at the start of treatment. B. Implement one‑to‑one observation during meal times. C. Establish consequences for purging behavior. D. Allow the client to select preferred meal times.

B. Implement one‑to‑one observation during meal times.

A nurse is providing teaching for a client who has schizophrenia and a new prescription for fluphenazine. Which of the following information should the nurse provide? A. "This medication might turn urine your orange." B. "Sleepiness should subside within a week." C. "Stop the medication if hypotension occurs." D. "A low-grade fever is expected with first doses."

B. "Sleepiness should subside within a week." Rationale: The nurse should inform the client that fluphenazine, like other first-generation antipsychotics, may cause sedation with early treatment, but should subside within a week or so.

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make? A. "Why do feel that you need to leave?" B. "You feel that you don't belong here." C. "We are here to help you and give you the care that you need right now." D. "Try to take some deep breaths and I'm sure you'll feel better."

B. "You feel that you don't belong here." Rationale: Restating is a therapeutic communication technique and encourages further dialogue.

A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make? A. "You are mistaken. Nobody is lying about you or trying to poison you." B. "You seem to be having very frightening thoughts." C. "Why do you think you are being lied about and poisoned?" D. "Who is lying about you and trying to poison you?"

B. "You seem to be having very frightening thoughts." Rationale: When responding to a client who is delusional, the nurse should avoid making statements that directly confront or affirm the client's delusional beliefs. Instead of responding literally to the client's words, the nurse should respond to the feelings that the client is attempting to communicate. By doing this, the nurse is shifting the focus from the delusional beliefs, which are not real, to the client's fear, which is real.

A nurse is assessing a client's withdrawal symptoms using the clinical institute withdrawal assessment of alcohol scale (CIWA). Which of the following scores would indicate a mild to moderate level of withdrawal? A. 6-15 B. 10-19 C. 20-30 D. 8-17

B. 10-19

Nursing priority of action for a client on Clozapine includes which of the following? (SATA) A. Call the provider if the client complains of increased thirst. B. Call the provider if the client complains of sore throat. C. Call the provider if the client complains of fever. D. Call the provider if the client complains of decreased weight.

B. Call the provider if the client complains of sore throat. C. Call the provider if the client complains of fever.

Which of the following are best interventions for a client w/cognitive decline/AD? (SATA) A. Confront when agitated B. Encourage reminiscence therapy C. Question hallucinations and insist they are not real D. Limit the number of choices when dressing or eating

B. Encourage reminiscence therapy D. Limit the number of choices when dressing or eating

Expected findings for a client with Delirium related to an acute urinary tract infection includes (SATA): A. Gradual memory loss and slow mood changes B. Fluctuating LOC C. Restlessness and hallucinations D. Rapid personality changes

B. Fluctuating LOC C. Restlessness and hallucinations D. Rapid personality changes

An home care RN has a client with AD. Nursing interventions to decrease injury includes which of the following? (SATA) A. Place rugs over electrical cords to prevent trips and falls. B. Install extra locks at the top of exit doors. C. Stairs should have adequate lighting to reduce the risk for falls D. Place the client's mattress on the floor.

B. Install extra locks at the top of exit doors. C. Stairs should have adequate lighting to reduce the risk for falls D. Place the client's mattress on the floor.

Tardive dyskinesia includes which of the following nursing considerations? (SATA) A. Once the antipsychotic med is discontinued, TD symptoms will decrease B. Monitor Involuntary movements of the tongue and face, such as lip smacking C. There are several reliable treatments for TD D. Monitor Involuntary movements of the arms, legs, and trunk

B. Monitor Involuntary movements of the tongue and face, such as lip smacking D. Monitor Involuntary movements of the arms, legs, and trunk

A client presents with psychosis. The nurse is preparing to administer Clozapine. Which of the following nursing actions is the highest priority with monitoring complications of Clozapine? A. Monitor for respirations and potential for respiratory complications B. Monitor for flu-like symptoms and potential for agranulocytosis C. Monitor for thoughts of lethality and potential side effects of suicidality D. Monitor for platelet counts and potential for bleeding

B. Monitor for flu-like symptoms and potential for agranulocytosis

Which are expected findings of bulimia nervosa (SATA) A. Amenorrhea and chronic headaches B. Normal or slightly elevated BMI C. Abnormal or low BMI D. Between binges, clients typically restrict caloric intake

B. Normal or slightly elevated BMI D. Between binges, clients typically restrict caloric intake

COMMON LABORATORY ABNORMALITIES ASSOCIATED WITH ANOREXIA AND BULIMIA (SATA): A. Low cholesterol B. Possible metabolic alkalosis or metabolic acidosis C. Anemia or leukopenia D. Possible electrolyte imbalance

B. Possible metabolic alkalosis or metabolic acidosis C. Anemia or leukopenia D. Possible electrolyte imbalance

CIWA is a screening tool for which condition and what score would indicate medical intervention? A. Withdrawal from opioids; 8-10 B. Withdrawal from alcohol; 11 + C. Withdrawal from heroin; over 10 D. Withdrawal from Benzos; 2-6

B. Withdrawal from alcohol; 11 +

Expected findings for a client with NCD include which of the following? A. aphasia, apraxia, alogia B. aphasia, agnosia, apraxia C. aphasia, avolition, anergia D. aphasia, anhedonia, agnosia

B. aphasia, agnosia, apraxia

A client with psychosis stares at the ceiling, mumbling. What is the nurse's priority action response? A. Stop the admission B. Ignore the behavior C. "What do you see on the ceiling? " D. "I see something there, too."

C. "What do you see on the ceiling? "

A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse verbalize during the session? A. "You should be aware that excessive sleeping is an early sign of relapse." B. "Relapse is an indication that you are not taking your medications properly." C. "You should keep your provider's and therapist's number with you." D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."

C. "You should keep your provider's and therapist's number with you." Rationale: The client should have a written plan, including important numbers, available at all times in case relapse occurs.

A nurse is caring for a client who has cocaine use disorder and is experiencing severe effects of intoxication. ALTERATION IN HEALTH (DIAGNOSIS)

Cocaine use disorder involves the repeated use of cocaine, leading to clinically significant impairment over a 12‐month period.

A nurse is caring for a client who has early stage Alzheimer's disease with a new prescription for Donepezil. The nurse should include which of the following statements when teaching the client about this medication? A. "You should take this medication in the middle of the day and you will have blood drawn to screen for underlying kidney disease prior to starting Donepezil." B. "You should take this medication before breakfast and avoid over-the-counter acetaminophen while on Donepezil." C. "You should take this medication before going to bed and avoid antihistamines while on Donepezil." D. "You should take this medication before a meal and avoid all over-the-counter medications."

C. "You should take this medication before going to bed and avoid antihistamines while on Donepezil."

A nurse is caring for a client dx w/AD w/script for donepezil. Med teaching includes: A. "You should stop taking donepezil if you experience nausea or diarrhea." B. "You will be screened for kidney dz prior to starting donepezil." C. "You should take this medication before going to bed." D. "You should avoid taking acetaminophen while on donepezil."

C. "You should take this medication before going to bed."

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse include in the teaching plan as negative symptoms? (Select all that apply.) A. Delusions B. Hallucinations C. Anhedonia D. Poor judgment E. Blunt affect

C. Anhedonia E. Blunt affect Rationale: Delusions is incorrect. Delusions are an example of a positive symptom of schizophrenia. Hallucinations is incorrect. Hallucinations are an example of a positive symptom of schizophrenia. Anhedonia is correct. Anhedonia is an example of a negative symptom of schizophrenia. Poor judgment is incorrect. Poor judgment is an example of a cognitive symptom of schizophrenia. Blunt affect is correct. Blunt affect is an example of a negative symptom of schizophrenia.

Which of these personality disorders may include a history of conduct disorder diagnosed before the age of 15? A. Borderline PD B. Narcissistic PD C. Antisocial PD D. Dependent PD

C. Antisocial PD

A nurse is caring for a client diagnosed with an eating disorder. Which of the following medications are contraindicated in clients with an eating disorder? A. Fluoxetine B. Buprenorphine C. Bupropion D. Lorazepam

C. Bupropion

A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia? A. Magical thinking B. Delusions of grandeur C. Ideas of reference D. Looseness of association

C. Ideas of reference Rationale: When ideas of reference are present, the client believes all events, situations, or interactions are directly related to him.

Patients diagnosed with co-occurring histrionic disorder require nurses to be consistent with which of the following? A. Mentoring to use assertiveness skills B. Giving assistance with motivation to finish tasks C. Maintaining professional boundaries and communication D. Assisting the patient to lessen feelings of inadequacy

C. Maintaining professional boundaries and communication

Nursing care for client diagnosed with an eating disorder include which of the following?

Consistency with care among staff; Encourage client decision making and participation in the plan of care; Consult with registered dietician for meal planning.

A positive CAM-ICU finding for Delirium includes which of the following? A. Gradual onset of mental status change B. No mental status changes from baseline C. Rapid or fluctuating onset of mental status change D. Occasional mental status change from baseline

C. Rapid or fluctuating onset of mental status change

Nursing action in the treatment of acute dystonia in EPS includes which of the following? A. Bupropion, IM or IV administration diphenhydramine, airway mgmt B. Benztropine, IM or IV administration diphenhydramine, airway mgmt C. Stop antipsychotic med, benztropine, IM or IV dipenhydramine, airway mgmt D. Continue antipsychotic meds, continue to monitor for further deterioration

C. Stop antipsychotic med, benztropine, IM or IV dipenhydramine, airway mgmt

Nursing action for neuroleptic malignant syndrome (NMS) includes which of the following? A. Stop antipsychotic, give Antipyretics, Benztropine, IM or IV diphenhydramine B. Stop antipsychotic, give Antipyretics, Bupropion IM or IV diphenhydramine C. Stop antipsychotic, Give Antipyretics, Dantrolene or Bromocriptine D. Stop antipsychotic, Give Antipyretics, Cyproh

C. Stop antipsychotic, Give Antipyretics, Dantrolene or Bromocriptine

A nurse is reviewing the history and physical of an adolescent client who has conduct disorder. Which of the following is an expected finding? A. Death of client's father two months ago B. Experiences frequent facial tics C. Suspended from school several times in the past year D. Adheres strictly to routines

C. Suspended from school several times in the past year Rationale: Conduct disorder is an impulse-control disorder which includes a long-term pattern of violating the rights of others and performing violent or hostile acts.

Clonidine for the treatment of opioid use: Which shows client understanding? A. "Taking this medication will help reduce my craving for heroin." B. "I can expect some diarrhea from taking this medicine." C. "Each dose of this medication should beplaced under my tongue to dissolve." D. "While taking this medication, I should keep a pack of sugarless gum."

D. "While taking this medication, I should keep a pack of sugarless gum."

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? A. Monitor the client closely to prevent self-mutilation. B. Set limits to prevent exploitation of other clients. C. Discourage flamboyant or seductive behaviors. D. Give positive feedback when client is assertive with staff or clients.

D. Give positive feedback when client is assertive with staff or clients. Rationale: The client who has dependent personality disorder has great difficulty demonstrating assertive behavior and commonly relies on others to make decisions. The nurse should encourage the client to be more assertive and independent.

Nursing care of clients who have potential for complications of Delirium include which of the following? A. Manage potential complications by using the FAST tool and provide a room away from the nurses' station to minimize high level stimulation B. Manage potential complications by using the COWS tool and provide a high level of visual and environmental stimuli C. Manage potential complication by using the GDS tool and provide a well-lit environment, minimizing contrasts and shadows D. Manage potential for complications by using the CAM-ICU tool and provide a well-lit room with low auditory stimuli

D. Manage potential for complications by using the CAM-ICU tool and provide a well-lit room with low auditory stimuli

The nurse will monitor for neuroleptic malignant syndrome observing for which of the following signs and symptoms? A. Sudden high fever, dry mouth, hyperreflexia B. Sudden high fever, diarrhea, hyperreflexia C. Sudden high fever, bradycardia, muscle rigidity D. Sudden high fever, diaphoresis, muscle rigidity

D. Sudden high fever, diaphoresis, muscle rigidity

The nurse knows that which of the following are true about the therapeutic use of Aripiprazole?

Decreased risk of EPSs or tardive dyskinesia, Treats both negative and positive symptoms, Lower risk for weight gain.

Which of the following are best interventions for a client with cognitive decline/AD?

Encourage reminiscence therapy; Limit the number of choices when dressing or eating.

The nurse will monitor signs and symptoms of serotonin syndrome which includes which of the following?

Fever, hallucinations, hyperreflexia

Negative symptoms of Schizophrenia include which of the following?

Flat affect, Avolition, Anergia

Expected findings for a client with delirium related to an acute urinary tract infection includes:

Fluctuating LOC; Restlessness and hallucinations; Rapid personality changes.

Client with co-occurring personality disorder often have which of the following risk factors?

History of SUD, violent or non-violent crimes; childhood abuse or trauma

Patients diagnosed with co-occurring histrionic disorder requires nurses to be consistent with which of the following?

Maintaining professional boundaries and communication.

Nursing considerations for Haloperidol include which of the following?

Monitor for Pseudoparkinsonism and anticholinergic adverse effects; Monitor for agranulocytosis and EPS.

Tardive dyskinesia includes which of the following nursing considerations?

Monitor involuntary movements of the tongue and face, like lip smacking; Monitor involuntary movements of the arms, legs, and trunk.

Which expected findings of bulimia nervosa:

Normal or slightly elevated BMI; Between binges, clients typically restrict caloric intake.

Nursing actions for Risperidone administration:

Obtain baseline fasting blood glucose, cholesterol, triglycerides; Monitor weight gain, urinary retention, hypotension; Don't give to dementia patients.

Nursing considerations for Risperidone include which of the following?

Obtain baseline fasting blood glucose; Monitor cholesterol & triglycerides; Hold medication for hypotension.

A positive CAM-ICU finding for Delirium includes which of the following?

Rapid or fluctuating onset of mental status change.

Nursing action in the treatment of acute dystonia in EPS includes which of the following?

Stop antipsychotic med, benztropine, IM, or IV diphenhydramine; airway management.

Nursing action for neuroleptic malignant syndrome include which of the following?

Stop antipsychotic, give antipyretic, dantrolene, or bromocriptine.

The nurse will monitor for neuroleptic malignant syndrome observing for which of the following signs and symptoms?

Sudden high fever, diaphoresis, muscle rigidity

A nurse is caring for a client who has anorexia nervosa of the restricting type. The client refuses to eat and exhibits severe anxiety when food is offered. The nurse plans to use desensitization as a behavioral therapy. INDICATIONS

Systematic desensitization is appropriate for clients who have anorexia nervosa and anxiety related to food and eating.

A nurse is caring for a client who has anorexia nervosa of the restricting type. The client refuses to eat and exhibits severe anxiety when food is offered. The nurse plans to use desensitization as a behavioral therapy. DESCRIPTION OF PROCEDURE

Systematic desensitization is the planned, progressive, or graduated exposure to anxiety‐provoking stimuli. During exposure, the anxiety response is suppressed through the use of relaxation techniques.