Spring ATI Week 8

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client demonstrates concrete thinking? A.) "I am aware that each problem has only one solution." B.) "I am a prophet of the most high judge." C.) "The voices tell me that I must avoid large crowds." D.) "I know that you are trying to poison me and you can't convince me otherwise."

A.) "I am aware that each problem has only one solution." This statement is an example of concrete thinking, which refers to the client's inability to think abstractly.

A nurse is caring for a client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse? A.) "I am going to leave now and I'll return in one hour to spend time with you then." B.) "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior." C.) "I'm very flattered, but I am married and cannot engage in this behavior." D.) "I'm curious as to why you are behaving this way. Can you please explain it to me?"

A.) "I am going to leave now and I'll return in one hour to spend time with you then." This statement is appropriate and makes it clear to the client that the behavior is not acceptable. Leaving gives the client an opportunity to gain control before the nurse returns.

A nurse working in a mental health facility is caring for a client who was involuntarily admitted. Which of the following client statements should the nurse recognize as accurate? (Select all that apply.) A.) "I do not have to take any medications." B.) "I have the right to ask the court to decide if I can be held here involuntarily." C.) "Before I agree to any treatment, you must tell me about my alternatives." D.) "My wife put me here, and now you can tell her anything I say." E.) "I am going to kill myself, and there is nothing you can do about it."

A.) "I do not have to take any medications." The client was involuntarily admitted and, therefore, has the right to refuse treatment, including medications. The nurse may be confronted with an ethical dilemma, such as autonomy vs. duty to protect. If the nurse questions the ability of the client to make sound judgments, the nurse should follow the agency protocol for investigating mental competence. B.) "I have the right to ask the court to decide if I can be held here involuntarily." State laws vary. Many states require medical certification, judicial review, or administration prior to the admission. Some states do not require a judicial hearing, but these states often provide the client with an opportunity for a judicial review after the admission. The agency must then immediately submit the client's petition to the court. Involuntary hospitalization generally lasts 60 to 180 days, but this can also vary. C.) "Before I agree to any treatment, you must tell me about my alternatives." All clients have the right to informed consent. The client should be informed of the nature of the problem or condition, the nature and purpose of a proposed treatment, the risks and benefits of the treatment, the alternative treatment options, the probability that the proposed treatment will be successful, and the risks of not consenting to treatment. Clients must be considered legally competent until they are proven legally incompetent through a legal hearing. If a client is deemed legally incompetent, a legal guardian is appointed to give or refuse consent.

A nurse is caring for a school-age child who has a terminal illness. His parents tell the nurse they have reluctantly taken the child's name off the list for participating in baseball this year. Which of the following responses should the nurse make? A.) "It must be frustrating for you to have to cancel an activity your son enjoyed." B.) "Baseball can be a dangerous sport for children anyway." C.) "You never know. He could be ready for baseball by next year." D.) "Why did you feel like you needed to do that?"

A.) "It must be frustrating for you to have to cancel an activity your son enjoyed." This response demonstrates the therapeutic communication technique of sharing empathy. It is neutral and nonjudgmental and invites further communication and sharing.

A nurse is caring for a 9-year-old child who has a new diagnosis of diabetes mellitus and tells the nurse that he is eager to return to school and participate in sports. The mother tells the nurse that she is afraid to let her take part in physical activities at school. Which of the following responses should the nurse make? A.) "Tell me more about how you are feeling about your daughter's activities." B.) "You might want to consider teaching your daughter at home." C.) "I agree. Her well-being is the most important thing." D.) "You sound overprotective. Let's talk about this some more."

A.) "Tell me more about how you are feeling about your daughter's activities." This response illustrates the therapeutic communication technique of exploring, and will encourage the mother to express her feelings and fears about her daughter's condition and physical activity.

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic? A.) "Tell me what makes you feel the client is doing this on purpose?" B.) "Next time this happens, tell me and I'll talk to the client about his behavior." C.) "You are probably right. Soiling the bed is a way of getting attention from the nursing staff." D.) "Why don't you spend more time with the client if you think that she is trying to get attention?"

A.) "Tell me what makes you feel the client is doing this on purpose?" This response encourages the AP to explore feelings that the client is soiling the bed for attention.

A nurse is caring for an older adult client admitted to the hospital following a cerebrovascular accident. The client's daughter tells the nurse, "I wish I could stay with my father, but I need to go home to my family." Which of the following responses should the nurse make? A.) "You are feeling drawn in two different directions." B.) "Don't worry. We'll take good care of your father while you are gone." C.) "Perhaps you could stay here and just call your family to see how they are doing." D.) "There's nothing you can do here. You should go home to your family."

A.) "You are feeling drawn in two different directions." This is an open-ended statement that reflects the daughter's feelings and encourages further communication.

A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following should information should the nurse include in the teaching? A.) "You might experience some temporary memory loss after the procedure." B.) "You will receive a medication to prevent seizure activity." C.) "These treatments should cure your depression." D.) "You will remain asleep for about 2 hr after the procedure."

A.) "You might experience some temporary memory loss after the procedure." Temporary memory loss can occur for a few hours after the procedure.

A nurse is discussing guided imagery with peers. Which of the following clients should the nurse identify as being a candidate for guided imagery? A.) A client who has post-traumatic stress disorder B.) A client who has schizophrenia C.) A client who has pedophilia D.) A client who has paranoid personality disorder

A.) A client who has post-traumatic stress disorder Guided imagery is a recommended treatment to relieve the anxiety associated with post-traumatic stress disorder.

A nurse in a community center is assisting with an educational session for caregivers of older adult clients who have dementia. Which of the following topics should the nurse include in the teaching session? (Select all that apply.) A.) Actions to reduce stress B.) Social support systems C.) Available community resources D.) Legal services E.) Maladaptive responses to grief

A.) Actions to reduce stress A caregiver may experience daily challenges when caring for a loved one. An increased stress level can lead to compounded frustration and manifest with elder abuse. Daily stressors can accumulate and should be addressed to avoid venting in a maladaptive manner. Stress reduction techniques include meditation, guided imagery, breathing exercises, physical exercises, relaxation exercises, journaling, and humor. B.) Social support systems Social interaction is a way of feeling supported and provides a healthy outlet for caregivers who may experience daily challenges of providing care to a loved one. C.) Available community resources Caregivers need to identify a social support system or people available to assist in the care of the older adult client. Studies indicate that social support minimizes stress, thus decreasing the risk of elder abuse. Nurses should make referrals to community resources, including emergency telephone numbers, numbers of 24-hr crisis centers or hotlines, respite programs in which volunteers care for the older adults, and support groups for caregivers. D.) Legal services The nurse should include the topic of legal services when providing an educational session for caregivers of older adult clients.

A nurse is reinforcing dietary teaching with a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which of the following foods should the nurse instruct the client to avoid while taking an MAOI? A.) Aged cheese B.) Milk C.) Shellfish D.) Canned tuna

A.) Aged cheese Aged foods, such as hard cheeses and meats, salami, and air-dried sausage, should be avoided when taking an MAOI. These can cause a dangerous increase in blood pressure.

A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse. Which of the following comorbidities should the nurse include in the discussion? (Select all that apply.) A.) Anxiety B.) ​Obsessive-compulsive disorder C.) Schizophrenia D.) ​Breathing-related sleep disorder E.) Depression

A.) Anxiety Anxiety is a comorbid condition common in clients who have an eating disorder. B.) ​Obsessive-compulsive disorder OCD is a comorbid condition common in clients who have an eating disorder, especially anorexia nervosa. E.) Depression Depression is a comorbid condition common in clients who have an eating disorder.

A nurse is discussing restraints with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client? A.) Continued self-destructive behavior B.) Refusal to take medication C.) Discipline for throwing chairs at staff D.) Inadequate staffing ratio between clients and health care providers

A.) Continued self-destructive behavior A nurse may use mechanical restraints for a client who presents a specific danger to themselves or others. The nurse must follow all facility policies, such as documentation of the behavior that led up to the use of restraints and other interventions the staff used prior to the restraints.

A nurse is assisting with a psychosocial assessment of an adolescent client. Which of the following factors indicate to the nurse a potential risk for suicide? (Select all that apply.) A.) Death of a parent at a young age B.) Recent or impending move C.) Low parental expectations D.) Sense of responsibility to family E.) Sudden decline in school performance

A.) Death of a parent at a young age A client considering suicide believes that the self-destructive act will end all problems and does not recognize the impact on others left behind. The death of a parent at a young age increases the risk for suicide due to maladaptive coping, dysfunctional grief, and impact on developmental growth. B.) Recent or impending move According to Erickson's psychosocial development, the adolescent achieves the milestone of role identity vs. role diffusion. This is a time of emancipation from the primary family members in an attempt to establish an identity separate from family. The adolescent's peer group becomes significant to him achieving and maintaining his role identity. A recent or impending move away from the peer group may be extremely stressful and foster feelings of hopelessness, loss, and pain. This is associated with an increased risk for suicide. C.) Low parental expectations The adolescent is navigating through a developmental stage that helps define their identity. Although his peer group is important during this time, the adolescent best responds to structure, responsibility, and well-defined roles within the home. This fosters security in the adolescent and promotes self-worth and self-esteem. Children who feel loved learn to love and value themselves. A lack of caring behaviors shown toward the child sends a clear message that he does not matter. E.) Sudden decline in school performance A sudden decline in the adolescent's school and/or sports performance may be a result of depression and/or substance abuse. This is a risk factor associated with suicide and should be addressed by the nurse.

A nurse is assessing a young adult client who has a new diagnosis of idiopathic juvenile arthritis. The client states, "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify that the client is using which of the following defense mechanisms? A.) Denial B.) Displacement C.) Rationalization D.) Reaction formation

A.) Denial By refusing to acknowledge or accept that she has a chronic disorder, the client is using the defense mechanism of denial.

A nurse is assisting with the admission assessment for a client who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority? A.) Determining if the client has thoughts of self-harm B.) Asking the client to identify the cause of the crisis C.) Identifying the client's coping skills D.) Identifying if friends or family are available to help

A.) Determining if the client has thoughts of self-harm Clients experiencing a situational crisis are at greatest risk for injury to themselves or others; therefore, determining if thoughts of self-harm are present is the nurse's priority.

A nurse is reviewing the medical record of a client who attempted suicide. Which of the following findings should the nurse identify as risk factors for suicide? (Select all that apply.) A.) Diagnosis of major depressive disorder B.) Unemployment C.) Pregnancy D.) Access to firearms E.) Recent marriage

A.) Diagnosis of major depressive disorder Co-occurring mental health disorders, which can interfere with coping skills, can increase a client's suicide risk. B.) Unemployment Unemployment, which can lead to feelings of hopelessness and financial problems, can increase a client's suicide risk. D.) Access to firearms Access to firearms increases a client's risk for suicide due to the availability of a weapon.

A nurse is collecting data an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following manifestations should the nurse expect to find? A.) Difficulty maintaining sustained attention B.) Difficulty using words in context C.) Difficulty in acquiring reading skills D.) Difficulty performing self-grooming activities

A.) Difficulty maintaining sustained attention An adolescent who has ADHD can have difficulty participating in activities that require following rules and maintaining attention. The adolescent can also demonstrate behaviors such as impulsiveness, anger, and aggression.

A nurse is collecting data from a client who is taking clozapine. Which of the following findings indicate the client is experiencing adverse effects of this medication? (Select all that apply.) A.) Drooling B.) Bradycardia C.) Tinnitus D.) Muscle rigidity E.) Elevated temperature

A.) Drooling Clozapine, an antipsychotic medication, can cause increased salivation, which can be a manifestation of neuroleptic malignant syndrome. D.) Muscle rigidity Muscle rigidity is an adverse effect of clozapine that can be a manifestation of neuroleptic malignant syndrome. E.) Elevated temperature Fever is an adverse effect of clozapine that can be a manifestation of neuroleptic malignant syndrome.

A nurse in a long-term care facility is performing a mental status examination (MSE) for a newly-admitted client who has dementia. Which of the following data should the nurse include? (Select all that apply.) A.) Grooming B.) Long-term memory C.) Support systems D.) Affect E.) Presence of pain

A.) Grooming Grooming is included in an MSE, which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. B.) Long-term memory Long-term memory is included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. D.) Affect Affect is included in an MSE, which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.

A nurse is collecting data from a school age child who has an intellectual development disorder. Which of the following findings should the nurse expect? A.) Has difficulty performing age-appropriate self-care activities B.) Distorts sounds when speaking C.) Demonstrates stereotypical movements D.) Shows a low frustration tolerance

A.) Has difficulty performing age-appropriate self-care activities A school age child who has an intellectual developmental disorder will likely have difficulty managing age-appropriate activities of daily living such as self-grooming, eating, and toileting. The school age child will also likely have deficits in intellectual functioning and social functioning.

A nurse is collecting data from a client who has agoraphobia. Which of the following prescriptions should the nurse anticipate the provider will prescribe? A.) Imipramine B.) Haloperidol C.) Verapamil D.) Bromocriptine

A.) Imipramine Imipramine is a tricyclic antidepressant that is effective in diminishing symptoms of agoraphobia.

A nurse is caring for a client who has schizophrenia and notices changes in the client's behavior. Which of the following behaviors is the nurse's priority to report to the provider? A.) Meaningless phrases B.) Refusal to eat snacks C.) Diminished facial affect D.) Decreased energy level

A.) Meaningless phrases A mixture of words or phrases that lack meaning are characterized by loose association in clients who have schizophrenia. It is an indication of disorientation, disorganization, and an alteration in mental cognition; therefore, it is the nurse's priority because of the threat to client safety and the safety of others.

A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe? A.) Methadone B.) Disulfiram C.) Risperidone D.) Lithium carbonate

A.) Methadone Methadone is a synthetic opiate that blocks the craving for and the effects of narcotics. It is widely used to assist with detoxification and maintenance of those who have a dependency on opioids. Methadone reduces withdrawal symptoms. The medication must be taken every day. The client requires close monitoring because methadone is highly addictive.

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.) A.) Muscle contractions of the neck B.) Fidgeting behavior C.) ​Fluctuating vital signs D.) ​Impaired gait E.) ​Sexual dysfunction

A.) Muscle contractions of the neck Muscle contractions of the neck are an example of EPS associated with conventional antipsychotics. B.) Fidgeting behavior Fidgeting behavior is an example of EPS associated with conventional antipsychotics. D.) ​Impaired gait Impaired gait is an example of EPS associated with conventional antipsychotics.

A nurse is reinforcing teaching with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the relapse prevention pain? A.) "I can remember when I started to relapse." B.) "I know which of my hallucinations trigger a relapse." C.) "I record the number of hallucinations I have each day." D.) "I will read as much information as I can about schizophrenia."

B.) "I know which of my hallucinations trigger a relapse." This statement indicates a client's understanding of relapse triggers and is an important component of a relapse prevention plan.

A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.) A.) Needle tracks B.) Skeletal deformities C.) Ecchymosis D.) Alopecia E.) Numbness

A.) Needle tracks The presence of needle tracks may indicate substance abuse and is a part of checking the integumentary system. C.) Ecchymoses The presence of ecchymoses can indicate injury or abuse and is a part of checking the integumentary system. D.) Alopecia The presence of alopecia, or hair loss, can indicate malnourishment and is a part of checking the integumentary system.

A nurse is contributing to the plan of care for a client who has signs of alcohol intoxication. Which of the following interventions should the nurse include in the client's plan of care? (Select all that apply.) A.) Obtain a blood sample. B.) ​Prepare the client for a CT scan. C.) ​Check the client's pupil reactivity. D.) Obtain a prescription for as-needed restraints. E.) Perform a developmental screening test.

A.) Obtain a blood sample. A blood sample allows for a blood alcohol level test, as well as other blood studies prescribed by the provider, to be performed. B.) ​Prepare the client for a CT scan. A CT scan and other neurological tests are performed to rule out brain injury or head trauma. C.) ​Check the client's pupil reactivity. Checking for pupil reactivity provides information about a client's neurological status.

A nurse is assisting the charge nurse to prepare for an inservice with nursing staff to discuss substance use disorders. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.) A.) Poor educational resources B.) Low self-esteem C.) Family history of addiction D.) Lack of support system E.) ​Asian ethnicity

A.) Poor educational resources Poor educational resources are related to poverty and socioeconomic factors contribute to chronic stress. B.) Low self-esteem Low self-esteem is considered a psychological factor associated with addictive disorders. C.) Family history of addiction Family history of addiction is an etiological factor associated with addictive disorders. D.) Lack of support system Lack of or an impaired support system is an etiological factor associated with substance use and addictive disorders.

A nurse is caring for a client who has schizophrenia and taking haloperidol. The nurse observes that the client has developed a stooped posture and shuffling gait. The nurse should document these findings as which of the following extrapyramidal side effects of haloperidol? A.) Pseudoparkinsonism B.) Acute dystonia C.) Akathisia D.) Tardive dyskinesias

A.) Pseudoparkinsonism Pseudoparkinsonism is an extrapyramidal side effect that includes findings such as a stooped posture, shuffling gait, tremor, drooling, and a mask-line facial expression.

A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take? A.) Reinforce how to use assertive communication techniques. B.) Schedule the client's daily self-care activities. C.) Set short-term and long-term goals for the client. D.) Discourage the client from expressing anger.

A.) Reinforce how to use assertive communication techniques. The nurse should reinforce how the client can use of assertive communication techniques when interacting with others. This can improve the client's self-esteem and increase a sense of control.

A nurse is discussing the possible physical effects of alcohol withdrawal with a newly licensed nurse. Which of the following effects should the nurse include? (Select all that apply.) A.) Seizures B.) Illusions C.) Tremors D.) Polyphagia E.) Nystagmus

A.) Seizures Seizures are an expected finding of alcohol withdrawal. B.) Illusions Illusions are an expected finding of alcohol withdrawal. C.) Tremors Tremors are an expected finding of alcohol withdrawal.

A nurse is discussing cultural concepts in mental health nursing with nursing staff. When discussing Native American clients, the nurse should identify which of the following as an increased risk for this cultural group? A.) Substance use B.) Schizophrenia C.) Personality disorders D.) Eating disorders

A.) Substance use Native American clients have an increased incidence of alcohol use disorder.

A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.) A.) Talking in rapid, continuous speech B.) Interacting with others in a flirtatious way C.) Reports spending large sums of money D.) Reports sleeping for long periods of time E.) Exhibiting clang associations

A.) Talking in rapid, continuous speech B.) Interacting with others in a flirtatious way C.) Reports spending large sums of money E.) Exhibiting clang associations

A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority? A.) The client will contact a staff member when she feels she might hurt herself. B.) The client will identify her position in the grief process. C.) The client will identify positive qualities about herself. D.) The client will identify ways to achieve a reachable goal for the future.

A.) The client will contact a staff member when she feels she might hurt herself. The greatest risk to this client is injury from self-harm. Therefore, the nurse should identify that the priority goal for the client is that she will seek help from a staff member when at risk for harming herself.

A nurse is collecting data from a client who has histrionic personality disorder. Which of the following characteristics should the nurse expect? A.) Uses physical appearance to gain attention. B.) Manipulates others for personal gain. C.) Unable to identify with the feelings of others. D.) Views self as inferior to others.

A.) Uses physical appearance to gain attention. A client who has histrionic personality disorder uses their physical appearance to gain attention to themselves.

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined? A.) Whether the client is a danger to herself or others. B.) Whether the client is unwilling to accept that treatment is needed. C.) Whether the client is unable to make arrangements to stay with someone. D.) Whether the client is financially incapable of paying for prescribed medications.

A.) Whether the client is a danger to herself or others. Clients who have mental health issues can be admitted for care voluntarily or involuntarily. The criteria for involuntary admission includes a statement of a legal opinion that the client has a mental health disorder that will likely result in serious bodily harm to the client, or another person, unless the client remains in a psychiatric facility.

A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make? A.) ​"Yes, I understand that you feel better wearing your bracelet." B.) ​"Why do you think the copper helps with your arthritis?" C.) ​"Believing objects have powers to make you feel better has no scientific basis." D.) ​"I think you should rely more on your medication therapy than on your bracelet."

A.) ​"Yes, I understand that you feel better wearing your bracelet." The nurse illustrates the therapeutic communication technique of accepting. The nurse demonstrates the knowledge that the bracelet is harmless for the client and shows respect for the client's beliefs.

A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse includes which of the following? (Select all that apply.) A.) ​Ability to perform calculations B.) ​Level of consciousness C.) Presence of suicidal thoughts D.) ​Long-term memory E.) ​Level of orientation

A.) ​Ability to perform calculations Evaluating the client's ability to perform calculations is an included component of an MSE. B.) ​Level of consciousness Determining the client's level of conscious is a component of an MSE. C.) Presence of suicidal thoughts Presence of suicidal thoughts is an included component of an MSE, along with details of a suicide plan. E.) ​Level of orientation Determining the client's level of orientation is an included component of an MSE.

A nurse is collecting data for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things". The nurse should recognize this finding as which of the following? A.) ​Command hallucination B.) ​Gustatory hallucination C.) ​Automatic obedience D.) ​Negativism

A.) ​Command hallucination The client is demonstrating a command hallucination. Command hallucinations involve the client hearing voices that command her to carry out some action. The nurse must monitor clients carefully for this type of hallucination, since they may command the client to do something that may cause self-harm or harm to others.

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect? A.) ​Significant change in weight B.) ​Hyperexcitability C.) ​Exaggerated response of pleasure to stimuli D.) ​Attention-seeking behavior

A.) ​Significant change in weight ​A significant change in weight, either loss or gain, is an expected finding of MDD.

A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which of the following is an appropriate intervention by the nurse? A.) Allow the client to continue talking so as not to interrupt the delusion. B.) Encourage the client to focus on reality-based issues. C.) Ask the client to explain the meaning behind what he is saying. D.) Persuade the client that his thoughts are not true.

B.) Encourage the client to focus on reality-based issues. Encouraging the client to focus on simple, concrete, reality-based topics is an appropriate approach to take with this client.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions is the nurse's priority? A.) Offer the client high-calorie fluids. B.) Remain with the client in a quiet area. C.) Administer an antianxiety medication to the client. D.) Teach the client relaxation exercises.

B.) Remain with the client in a quiet area. The nurse should not leave a client who has severe anxiety alone. The nurse's priority is the safety of the client and to use the least restrictive intervention, such as staying with the client in a quiet area and calmly encouraging him to express his feelings.

A nurse is reinforcing teaching with a client who is to start taking lithium carbonate. Which of the following dietary supplements should the nurse instruct the client to avoid? A.) Black cohosh B.) St. John's wort C.) Ginkgo biloba D.) Ginger root

B.) St. John's wort Taking St. John's wort while taking lithium carbonate can lead to serotonin syndrome because both agents increase serotonin transmission.

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.) A.) "I sleep in in the mornings." B.) "I call a friend who makes me smile and laugh." C.) "I think about being on my favorite beach vacation." D.) "I tense and release my muscles, starting with my feet." E.) "I isolate myself in my room for a few hours when things get overwhelming."

B.) "I call a friend who makes me smile and laugh." Humor can be used to turn a stressful situation around. The intensity attached to a stressful thought or situation can be decreased when it is made to appear absurd or comical. Laughter has been shown to increase the release of endorphins, which promote a sense of well-being. C.) "I think about being on my favorite beach vacation." Guided imagery is a process whereby a person is led to envision images that are both calming and health-enhancing. These pleasant thoughts replace negative or stressful feelings. D.) "I tense and release my muscles, starting with my feet." Progressive muscle relaxation (PMR) can be accomplished by tensing groups of muscles, beginning with the feet and ending with the face, as tightly as possible for 8 seconds and suddenly releasing them. This procedure causes a physical relaxation response and can decrease anxiety.

During a group therapy session, a nurse observes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the use of maladaptive coping mechanisms? A.) "I wrote a short story about a heroic woman when I was really mad at my boss." B.) "I don't care about work anymore since I was not given a promotion." C.) "I mentally separate myself from distractions around me when I paint on canvas." D.) "I still cannot remember the scene of my husband's car accident."

B.) "I don't care about work anymore since I was not given a promotion." Regression is reverting to an earlier, more primitive and child-like pattern of behavior. If a promotion is lost, maladaptive regression is seen through poor work performance, missing appointments, and being late.

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make? A.) "You really should work hard to stay on the schedule we establish here." B.) "Let's work together to devise a schedule that is convenient for you on a daily basis." C.) "Why do you find it difficult to take your medications if they improve your condition?" D.) "I wouldn't worry about what you've done in the past. You'll do just fine this time."

B.) "Let's work together to devise a schedule that is convenient for you on a daily basis." This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the client's needs at this time.

A nurse enters the community room of an acute mental health unit and observes a client yelling at another client. Which of the following statements should the nurse make to the client? A.) "Why did you hit another client?" B.) "Yelling at others is unacceptable." C.) "Your behavior will be disappointing to your provider." D.) "I'm taking away your privileges for the rest of the week."

B.) "Yelling at others is unacceptable." The nurse should set clear limits on specific behaviors so it is important to tell the client that yelling is unacceptable behavior. The nurse should use de-escalation techniques, such as responding as early as possible, remaining calm, and assessing for personal safety.

A nurse is reinforcing teaching with a client who has major depressive disorder and a new prescription for fluoxetine. Which of the following statements should the nurse make to the client? A.) "You should plan to eat several snacks every day because fluoxetine causes weight loss." B.) "You could experience withdrawal manifestations if you stop taking fluoxetine abruptly." C.) "You are likely to experience dizziness or fainting if you get up out of bed quickly." D.) "You can take fluoxetine with St. John's wort to obtain increased antidepressant effects."

B.) "You could experience withdrawal manifestations if you stop taking fluoxetine abruptly." Abrupt discontinuation of fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) can cause headache, dizziness, anxiety, and other manifestations. The nurse should instruct the client not to stop fluoxetine abruptly but to notify the provider for adverse effects. The medication dosage can be tapered gradually to prevent withdrawal.

A nurse is assisting with a conflict-resolution group for adolescent clients in a community clinic facility. Which of the following clients should the nurse identify as being the highest risk for a suicide attempt? A.) A client who stated she is feeling anxious about going to a new school in the fall B.) A client who attempted suicide the previous year C.) A client whose family enjoys target shooting with guns D.) A client with deep religious views whose father recently died in an automobile crash

B.) A client who attempted suicide the previous year Suicide is the second-leading cause of death among adolescents. The nurse must listen carefully to any young person who speaks about harming herself or others. The highest risk for a suicide attempt is a previous suicide attempt; therefore, according to evidence-based practice, collecting data regarding a suicide attempt for this client should be the nurse's priority.

A nurse in a long-term care setting is caring for a client who has Alzheimer's disease. The client states, "I just came back from a hard day's work in my office." The nurse should identify this statement is an example of which of the following coping mechanisms? A.) Perseveration B.) Confabulation C.) Thought deletion D.) Tangentiality

B.) Confabulation Confabulation is the creation of information which is untrue to fill in gaps in memory and to protect self-esteem in clients who have dementia.

A nurse is assisting in the care of a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions? A.) Persecution B.) Control C.) Erotomanic D.) Somatic

B.) Control A client who is experiencing a control delusion believes that other are trying to control him; this is often believed to be by forcing thoughts into the brain.

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take? A.) Interrupt the compulsive behavior. B.) Determine the client's level of anxiety C.) Encourage avoidance of situations that increase anxiety. D.) Use negative reinforcement techniques to prevent client from performing rituals.

B.) Determine the client's level of anxiety Obsessions are recurrent, persistent, and impulsive thoughts that increase anxiety. Compulsions are repetitive behaviors performed in an attempt to decrease anxiety. Determining the client's level of anxiety is important because it can help the nurse plan appropriate interventions. The client who has mild or moderate anxiety can participate in care planning. If the client has severe or panic-level anxiety, the nurse should direct care for the client until anxiety decreases.

A provider tells a client who has an anterior cruciate ligament that he may not play football for the remainder of the season. The client yells that the provider doesn't know what he is talking about and kicks a chair. Which of the following defense mechanisms is the client demonstrating? A.) Denial B.) Displacement C.) Rationalization D.) Reaction formation

B.) Displacement The client is demonstrating displacement when he shifts feelings about an object, person, or situation to another less threatening object, person, or situation. The client transferred his emotional reaction about the injury and inability to play to the provider and to the chair.

A nurse is assisting with the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse recommend to include? A.) Provide a stimulating environment. B.) Encourage short rest periods throughout the day. C.) Encourage group activities. D.) Schedule daily seclusion times.

B.) Encourage short rest periods throughout the day. The nurse should provide short rest periods throughout the day because the client might not be aware of developing fatigue from hyperactivity. The client is at risk for injury without sufficient rest

A nurse is collecting data from a client who is experiencing alcohol withdrawal delirium. Which of the following findings should the nurse expect? (Select all that apply.) A.) Hypotension B.) Visual hallucinations C.) Grandiosity D.) Paranoid delusions E.) Tremors

B.) Visual hallucinations Visual hallucinations are an expected finding of alcohol withdrawal delirium. D.) Paranoid delusions Paranoid delusions are an expected finding of alcohol withdrawal delirium. E.) Tremors Tremors are an expected finding of alcohol withdrawal delirium.

A nurse is caring for a client who is experiencing acute anxiety. Which of the following actions should the nurse take? (Select all that apply.) A.) Avoid eye contact when addressing the client. B.) Establish rapport with the client. C.) ​Identify the cause of the anxiety. D.) ​Validate the client's feelings. E.) Speak to the client using a high-pitched voice.

B.) Establish rapport with the client. Establishing a rapport with the client is an appropriate crisis intervention. C.) ​Identify the cause of the anxiety. Identifying the cause of the client's anxiety is an appropriate crisis intervention. D.) ​Validate the client's feelings. Validating the client's feelings is an appropriate crisis intervention.

A nurse is participating in a planning a support group for client who recently experienced a loss of a family member. Which of the following actions should the nurse plan for the leader to take during the working phase of the group? A.) State the purpose of the group. B.) Focus on problem solving. C.) Discuss confidentiality issues D.) Encourage members to reflect on their progress.

B.) Focus on problem solving. The leader should focus on problem solving that relates to the purpose of the group during the working phase.

A nurse is planning to meet with a client for the first time to start developing a helping relationship. Which of the following actions should take the nurse take during the orientation phase? A.) Summarize goals the client achieved. B.) Formulate a contract. C.) Gather further data. D.) Promote the client's self-esteem.

B.) Formulate a contract. The nurse should formulate a contract that identifies the nurse's and client's responsibilities during the relationship. This can include where they will meet, how frequently, and for how long.

A nurse is caring for a client who has depression and is discussing ADLS with his family. The nurse identifies that, after, discharge, the client is able to perform which of the following if independent with ADLs? A.) Driving B.) Hygiene C.) House cleaning D.) Grocery shopping

B.) Hygiene The ability to maintain personal hygiene is an essential functional ability included in ADLs.

A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (Select all that apply.) A.) Inability to find commonly used items B.) Inability to perform common tasks C.) Exhibits wandering behaviors D.) Difficulty remembering how to swallow E.) Inability to recognize family members

B.) Inability to perform common tasks People at this stage may also experience difficulty handling money and finding their way home. This can be a very frightening experience for people because they are aware of the problem. C.) Exhibits wandering behaviors In the moderate stage of Alzheimer's disease, the client has a tendency to wander and may become lost. Although the client may recall his name, he will often not remember where he is from or his home address. This stage of dementia may also include the inability to walk. Toileting problems may occur. All self-care abilities will be compromised. At this point, the client may have difficulty eating without assistance.

A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect? A.) Decreased cholesterol levels B.) Low bone density C.) Heavy monthly periods D.) Elevated serum potassium level

B.) Low bone density A client who has anorexia nervosa is likely to have low bone density, called osteoporosis, due to low calcium intake and estrogen deficiency.

A nurse on an impatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.) A.) Give the client a weight gain goal of 4 to 5 lb per week. B.) Monitor the client's weight daily after first voiding. C.) Encourage the client to keep a diary of daily food intake. D.) Stay with the client during meals and for 1 hr afterward. E.) Offer specific privileges for sustained weight gain.

B.) Monitor the client's weight daily after first voiding. Daily weighing makes it difficult for the client to hide weight loss. The nurse should weigh the client daily after his first void in the morning. C.) Encourage the client to keep a diary of daily food intake. A food diary provides the client the opportunity to see a realistic picture of their food intake on a daily basis. D.) Stay with the client during meals and for 1 hr afterward. The nurse should offer support and encouragement at mealtimes, but also monitor the client's behavior to prevent purging following food ingestion. E.) Offer specific privileges for sustained weight gain. Positive reinforcement includes rewards for improvements in eating behaviors and is an appropriate strategy for clients who have eating disorders.

A nurse is caring for a client who is experiencing an uncomplicated grief reaction. Which of the following is an expected finding? A.) Disturbed self-esteem B.) Openly expresses anger C.) Generalized feelings of guilt D.) Rejects support from others

B.) Openly expresses anger A client who is experiencing an uncomplicated grief reaction is usually able to openly express her anger. According to Kubler-Ross, anger is the second stage of the normal grief process.

A nurse is assisting is collecting data from a client who has acute phencyclidine (PCP) intoxication. Which of the following findings should the nurse expect? A.) Bradycardia B.) Paranoia C.) Hypoglycemia D.) Hyperphagia

B.) Paranoia PCP intoxication causes feelings of paranoia and panic.

A nurse is collecting data from a client whose husband died during a hurricane one year ago. The client reports having nightmares about the hurricane, persistent thoughts of blaming herself for her husband's death, and has stopped participating in her usual activities. The nurse should identify that the client is experiencing which of the following disorders? A.) Dependent personality disorder B.) Posttraumatic stress disorder C.) Histrionic personality disorder D.) Obsessive personality disorder

B.) Posttraumatic stress disorder A client who has recurrent, distressing dreams about a particular event, persistent distorted thoughts about the event, and is no longer participating in usual activities is likely to be experiencing posttraumatic stress disorder. The client can also have persistent distressing memories of the event and persistent fear, anger, or guilt.

A nurse is collecting data from a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.) A.) ​Short attention span B.) ​Delayed language development C.) ​Spins a toy repetitively D.) ​Ritualistic behavior E.) ​Consistent limit-testing

B.) ​Delayed language development A delay in speech and language development is an expected finding of autism spectrum disorder. C.) ​Spins a toy repetitively Interest in repetitive activities is an expected finding of autism spectrum disorder. D.) ​Ritualistic behavior A need for routine and the presence of ritualistic behavior are expected findings of autism spectrum disorder.

A nurse is assisting in the care of a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings should the nurse document the client is exhibiting? A.) ​Flight of ideas B.) ​Grandiosity C.) ​Reality testing D.) ​Derealization

B.) ​Grandiosity ​Grandiosity refers to the client's belief that he has special abilities.

A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding? A.) ​Hypotension B.) ​Viral infection C.) ​Increased energy D.) ​Increased cognitive awareness

B.) ​Viral infection The nurse should expect to find the client with a decreased immune response due to increased corticosteroid production, which leads to viral or bacterial infections in response to chronic stress.

A nurse is assisting with a family therapy session for parents and 2 school-age children. Which of the following statements should the nurse recognize as an example of effective communication among family members? A.) "If you keep saying that, I will tell everyone what you did last night." B.) "She is always bossing me around. Should she do that?" C.) "Can you tell me the reason you get upset each time I go to the mall?" D.) "Please do not raise your voice at the children. I am the one who left dishes in the sink."

C.) "Can you tell me the reason you get upset each time I go to the mall?" This is an example of effective and healthy communication. Healthy communication expresses clear, understandable messages between family members. Each family member is encouraged to express his or her own feelings and thoughts. The communication is clear, understandable, and direct. This communication technique promotes an open exchange of feelings and thoughts.

A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information? A.) "I need to decrease my sodium intake while on this medication." B.) "This medication can cause a dry cough." C.) "I should call the provider if I experience excessive sweating and muscle twitching." D.) "This medication can cause harmless, temporary changes to my ability to taste and smell."

C.) "I should call the provider if I experience excessive sweating and muscle twitching." Sertraline and other selective serotonin reuptake inhibitors can cause serotonin syndrome, characterized by agitation, anxiety, hallucinations, hyperactive reflexes, excessive diaphoresis, and hyperthermia. This condition can cause death; the client should report these findings to the provider so the medication can be safely discontinued.

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following statements by the client indicates that the client is in the denial phase of the grief process? A.) "The doctor has been so good to me. I know he has tried everything he can. It is just my time." B.) "I can't believe that doctor graduated from medical school! He doesn't know a thing about treating cancer." C.) "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." D.) "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed."

C.) "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." This client statement is an example of denial. The Five Stages of Grief may not be experienced in order, and the length of each stage will vary from person to person. In the denial stage, clients have difficulty believing a terminal diagnosis or loss. In the anger stage, clients lash out at other people or things. In the bargaining stage, clients negotiate for more time or a cure. In the depression stage, clients are saddened over the inability to change the situation. In the acceptance stage, clients accept what is happening and plan for the future.

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate? A.) "You need to tell the voices to leave you alone." B.) "You need to understand that there are no voices." C.) "What are the voices telling you to do?" D.) "Why do you think you are hearing the voices?"

C.) "What are the voices telling you to do?" This statement recognizes the risk involved with a command hallucination and asks the client directly about the hallucination. This is a therapeutic approach to communicating with a client who is experiencing a hallucination.

A nurse is caring for a group of clients on a mental health unit. Which of the following clients should the nurse recognize as utilizing a maladaptive defense mechanism? A.) A client slams a drawer after misplacing her wallet. B.) A client who used to smoke 3 packs of cigarettes daily now volunteers with a smoking cessation group. C.) A client is afraid to begin chemotherapy and forgets to schedule necessary appointments. D.) A client who is scheduled for oral surgery ignores the thought of pain.

C.) A client is afraid to begin chemotherapy and forgets to schedule necessary appointments. Repression occurs when a person deals with anxiety by unconsciously putting the unacceptable or stress-producing thought out of her consciousness. In this case, the repression is maladaptive because the client is not receiving the appropriate health care. A delay in chemotherapy may make the therapy ineffective. The defense mechanism is considered maladaptive if the action interferes with healthy functioning, either physically or mentally.

A nurse is caring for a client in the emergency department who has a traumatic amputation of his left arm in an industrial accident 1 hr ago. The nurse should expect the client to be in which of the following stages of grief? A.) Bargaining B.) Depression C.) Denial D.) Acceptance

C.) Denial According to Kubler-Ross, denial is the first of five stage of grieving. Although each individual experiences grief differently, the first stage is often denial. At this point, the client has not yet come to terms with the fact that he has lost an extremity. He likely expects reattachment or may even perceive that his arm is still there.

A nurse is caring for a client who is taking clozapine for the treatment of schizophrenia. The nurse should monitor the client for which of the following potential adverse effects of clozapine? A.) Pain in great toes B.) Hypoglycemia C.) Dry mouth D.) Diarrhea

C.) Dry mouth The nurse should monitor the client for dry mouth, which is a potential anticholinergic effect of clozapine.

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first? A.) Review the client's toxicology laboratory report. B.) Make a contract with the client for weight gain. C.) Initiate one-to-one nursing observation. D.) Administer the Hamilton depression scale.

C.) Initiate one-to-one nursing observation. A recent suicide attempt indicates that this client is at greatest risk for another attempt; therefore, the first action the nurse should take is to initiate one-to-one nursing observation to provide continuous monitoring.

A nurse is caring for a client who is exhibiting signs of serotonin syndrome. Which of the following is the nurse's priority intervention? A.) Administering an anticonvulsant B.) Administering diazepam C.) Preparing for artificial ventilation D.) Applying a cooling blanket

C.) Preparing for artificial ventilation Preparing for artificial ventilation is the priority intervention when taking the airway, breathing, circulation approach to client care.

A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a substance use disorder. He tells the nurse that he first began using illicit drugs when his parents wouldn't allow him to get a tattoo. Which of the following defense mechanisms is the client demonstrating? A.) Suppression B.) Intellectualization C.) Projection D.) Dissociation

C.) Projection The client uses projection when he blames others for unacceptable thoughts and feelings. Rather than accepting blame for his choice to use illicit drugs, the client projects that blame onto his parents.

A nurse is caring for a client who has generalized anxiety disorder. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need to be taken care of." The nurse should identify this behavior as the maladaptive use of which of the following defense mechanisms? A.) Dissociation B.) Introjection C.) Regression D.) Repression

C.) Regression This client is demonstrating the maladaptive use of regression which is the mechanism of reverting to childlike or immature behaviors.

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following nursing interventions is appropriate? A.) Warn the client that further disruptions will result in seclusion. B.) Ignore the client's behavior, realizing that it is consistent with her illness. C.) Set limits on the client's behavior and be consistent in approach. D.) Ask the client to recommend consequences for disruptive behavior.

C.) Set limits on the client's behavior and be consistent in approach. When caring for a client who is experiencing a manic episode, the nurse should communicate acceptable behavior to the client and should be consistent with negative consequences when the behavior plan is not followed.

A nurse is reviewing the nursing history for an adolescent client who has a new diagnosis of conduct disorder. Which of the following findings is consistent with characteristics of this disorder? A.) Verbalizes presence of auditory hallucinations. B.) Has frequent facial tics. C.) Starts physical fights with peers at school. D.) Develops signs of stress when school routines are changed.

C.) Starts physical fights with peers at school. This finding is consistent with characteristics of conduct disorder, which is characterized by impulsive, aggressive, violent, and often unlawful behavior.

A nurse is caring for a client who is has an anxiety disorder and how has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first? A.) Ask the client what precipitated this anxiety. B.) Offer the client a prescribed antianxiety medication. C.) Tell the client you will remain with her. D.) Take the client to a quiet room.

C.) Tell the client you will remain with her. The greatest risk to this client is that she will harm herself by pacing and hyperventilating and that her anxiety will increase even further. Telling the client that the nurse will remaining with the client provides a feeling of safety and is the priority action for the nurse to perform at this time.

A nurse is caring for a client who has schizophrenia. The nurse observes that the client consistently does the opposite of what he is told. The nurse recognizes this as which of the following alterations in behavior? A.) ​Automatic obedience B.) ​Waxy flexibility C.) ​Negativism D.) ​Impaired impulse control

C.) ​Negativism ​This behavior is correctly identified as negativism.

A nurse is caring for a client who has cancer. The client states that she wants to try nontraditional treatments instead of the chemotherapy recommended by her provider. Which of the following responses should the nurse make? A.) "Using nontraditional treatments is not a good Idea. I'd rather you avoid that route." B.) "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice." C.) "Your doctor is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you." D.) "Tell me more about your concerns about chemotherapy."

D.) "Tell me more about your concerns about chemotherapy." Asking the client to talk more about her fears and her concerns encourages communication. It is an example of the therapeutic communication technique of exploring.

A charge nurse overheats another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following responses by the nurse requires the charge nurse to intervene? A.) ​"Tell me who you are." B.) "I don't understand. Can you tell me what that means?" C.) "Are you saying that you are both good and bad?" D.) "There is no gate."

D.) "There is no gate." This reply can be viewed as argumentative by the client and is nontherapeutic when communicating with a client who is experiencing a delusion.

A nurse is caring for a client who is scheduled for electroconvulsive therapy in 1 hr. The client asks the nurse, "Can I refuse today's treatment?" Which of the following responses should the nurse make? A.) "You will be discharged sooner if you have the prescribed ECT treatments." B.) "You are admitted to a mental health facility and must follow the provider's orders." C.) "You have already signed the consent form, so you cannot refuse today's treatment." D.) "You have the right to refuse the treatment."

D.) "You have the right to refuse the treatment." Informed consent is a communication between provider and client regarding the risks and benefits of treatment. The client authorizes the treatment with a witnessed signature to undergo the medical intervention. The client has the right to refuse or delay treatment, even though the informed consent has been signed. The nurse's role is to demonstrate client advocacy and provide support.

A nurse is reinforcing teaching with the parents of a school-age child who has a new prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include? A.) "Limit your child's caloric intake to prevent excessive weight gain." B.) "Your child might pass large amounts of very light-colored urine." C.) "You should expect hyperactivity as a common adverse effect of atomoxetine." D.) "Give your child's medication dose in the morning."

D.) "Give your child's medication dose in the morning." Insomnia is a common side effect of atomoxetine. Administering the dose in the morning will help prevent this side effect. If two doses per day are prescribed, the second dose should be administered no later than 1600 to prevent insomnia.

A nurse is reinforcing teaching with a client who is to begin taking paroxetine. Which of the following statements by the client indicates an understanding of the teaching? A.) "I might experience an increased desire to have sex." B.) "My blood pressure might increase." C.) "I might notice that I have more saliva." D.) "I might not feel like eating as much."

D.) "I might not feel like eating as much." Anorexia and a decreased appetite are adverse effects of paroxetine.

A nurse on the hospice unit is caring for a newly-admitted client. Which of the following client statements is the nurse's priority? A.) "I am becoming sleepy after I take pain medication." B.) "I would go to church every day if it meant getting more time." C.) "I cannot wait to see my family later today." D.) "I plan to take an antiaging supplement I brought from home."

D.) "I plan to take an antiaging supplement I brought from home." Antiaging supplements and herbal remedies pose a danger to the client when they interact with other prescription and over-the-counter medications. Although it is not unusual for dying persons to hold on to the hope of a miracle cure, the nurse must protect client safety. Information regarding all botanical supplements should be provided to the provider to determine contraindications, risk of adverse effects, and incompatibilities. In addition, the provider will need to approve and write a prescription. The client's safety should be of most concern to the nurse, even in the final stages of dying. As a nurse, safe and effective care is an essential component to the delivery of client care. This statement is representative of denial, which is the first stage of grief.

A nurse is reinforcing teaching with a client who has a prescription for nortriptyline. Which of the following client statements indicates an understanding of the teaching? A.) "I may experience an increased libido." B.) "I can no longer eat pepperoni pizza." C.) "I will avoid drinking caffeinated beverages." D.) "I should sit on the side of the bed before standing up in the morning."

D.) "I should sit on the side of the bed before standing up in the morning." Nortriptyline can cause orthostatic hypotension; therefore, the client should rise slowly in the morning.

A nurse is talking to a client who is explaining about her home situation and the intimate partner violence she recently experienced. Which of the following responses should the nurse make? A.) "Why do you think your partner is angry with you?" B.) "Now that you have come for help, you will feel much better." C.) "Let's talk about what is going on at work." D.) "I'd like to hear more about how you are feeling."

D.) "I'd like to hear more about how you are feeling." The nurse is offering a general lead to allow the client to express her feelings. The nurse is communicating caring which can promote trust.

A nurse is assisting with the admission of a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they discover I have cancer." Which of the following responses should the nurse make? A.) "Why do you think you might have cancer when your diagnosis is a benign condition?" B.) "I have reviewed your history and I don't see any reason for you to worry about that." C.) "I think that's something you need to discuss further with your doctor." D.) "I'm hearing that you are concerned that you could have cancer."

D.) "I'm hearing that you are concerned that you could have cancer." This response illustrates the therapeutic communication technique of seeking clarification and restating. It demonstrates the nurse's willingness to explore the client's fears and encourages communication.

A nurse in an outpatient clinic is caring for a client who reports bilateral knee pain after a hike in the mountains this past weekend. He tells the nurse that he is worried because his cousin died from bone cancer recently. Which of the following responses should the nurse make? A.) "I wouldn't worry about that. It's unlikely that you have cancer." B.) "Why do you think your pain isn't just a result of the hike?" C.) "I completely understand why you're concerned about this." D.) "You seem worried. Let's talk about how you are feeling."

D.) "You seem worried. Let's talk about how you are feeling." This response illustrates the therapeutic communication technique of making observations. This technique causes the client to notice his behavior and describe his thoughts and feelings.

A nurse in an acute care mental health facility is caring for a client who begins to yell and scream at staff members. Which of the following actions is the nurse's priority? A.) Administer haloperidol IM to the client. B.) Place the client in restraints. C.) Move the client to a seclusion room with continuous observation. D.) Ask the client to talk about his feelings.

D.) Ask the client to talk about his feelings. The nurse's immediate priority when faced with a client who is potentially violent is to maintain safety while attempting to de-escalate the client's behavior. Therapeutic communication in short sentences helps defuse anger and offers understanding and support. This demonstrates the nurse's approachability and desire to help while listening. While speaking to the client, the nurse should maintain a calm demeanor and voice while providing a wide personal space and leaving a personal escape route.

A nurse is collecting data from a client who has schizophrenia. The client states, "I feel like my hands and feet belong to someone else." The nurse should interpret this statement as which of the following alterations? A.) Derealization B.) Motor retardation C.) Waxy flexibility D.) Depersonalization

D.) Depersonalization Depersonalization is a perceptual alteration in which the client either feels his entire identity is lost or that parts of his body do not belong to him.

A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has alcohol use disorder. Which of the following interventions is the nurse's priority? A.) Pad the side rails of the bed with towels. B.) Place the client in a private room. C.) Accompany the client when ambulating. D.) Determine the client's level of disorientation.

D.) Determine the client's level of disorientation. The greatest risk to the client is injury and adverse effects of withdrawal; therefore, this intervention is the highest priority of the nurse.

A nurse in a community clinic is caring for a client whose partner was just killed by a drunk driver. The client states, "I have no idea how I even got here. I cannot think right now." Which of the following actions should the nurse take first? A.) Help the client to identify personal strengths he can use in a crisis situation. B.) Identify a support person to notify and to take the client home. C.) Assist the client in prioritizing decisions that must be made. D.) Determine whether the client is at risk for self-harm.

D.) Determine whether the client is at risk for self-harm. The client's situation indicates that he is at greatest risk for harming himself. The nurse should make safety the priority in a crisis situation and should institute measures to determine whether the client is at risk for either suicidal or homicidal thoughts. Following this appraisal, the nurse can implement other interventions to decrease the client's anxiety and assist the client in taking necessary actions.

A nurse is assisting with an admission assessment for a client who has vegetative signs of depression. Which of the following is an appropriate intervention to recommend including in the plan of care? A.) Discourage rest only at bedtime. B.) Instruct family to avoid visiting during mealtimes. C.) Offer frequent, low-calorie snacks. D.) Developing a structured routine for the client to follow.

D.) Developing a structured routine for the client to follow. Clients who have vegetative signs of depression benefit from a structured routine and step-by-step instructions.

A nurse at an urgent care center is caring for a client who sustained minor injuries during a street fight in which two of the client's friends were stabbing victims. The client tells the nurse that he doesn't remember anything that happened after he and his friends first saw the suspects in the stabbing. Which of the following defense mechanisms is the client demonstrating? A.) Suppression B.) Sublimation C.) Projection D.) Dissociation

D.) Dissociation The client is demonstrating dissociation to temporarily block memories and perceptions from consciousness. This client is dissociating from the incident in which he and his friends were injured.

A nurse is collecting data from a client who has schizophrenia and is taking fluphenazine. The nurse observes that the client's tongue is protruding and he has irregular movements of his limbs. The nurse should identify that the client is exhibiting manifestations of which of the following? A.) A reaction to drinking grapefruit juice with the medication. B.) Missing a dose of the medication. C.) Early symptoms of a psychotic episode. D.) Early symptoms of tardive dyskinesia.

D.) Early symptoms of tardive dyskinesia. A protruding tongue and irregular limb movements are signs of tardive dyskinesia.

A nurse is interviewing a client who has a personality disorder. The nurse and client have agreed on an interview time, but the client resists discussing her feelings until 5 min prior to the end of the session and then asks for additional time. Which of the following actions should the nurse take? A.) Extend the scheduled time, as the client is finally able to discuss important feelings. B.) Arrange for another nurse to continue the interview. C.) Set an extra meeting time to discuss the client's feelings. D.) End at the scheduled time, telling the client that he can continue at the next scheduled session.

D.) End at the scheduled time, telling the client that he can continue at the next scheduled session. Clients who have a personality disorder often use manipulation. Setting limits discourages this behavior and is an appropriate intervention. In this case, the nurse and client have agreed on a time limit and the nurse should firmly and calmly assure that the time is not exceeded.

A nurse is contributing to the plan of care for a child who has autism spectrum disorder. Which of the following interventions should the nurse recommend for the plan of care? A.) Assure that child has a large variety of caregivers. B.) Provide a flexible schedule to adjust to the child's interests. C.) Allow for imaginative play with peers without supervision. D.) Establish a reward system for positive behavior.

D.) Establish a reward system for positive behavior. Children who have autism spectrum disorder benefit from a reward system for positive behavior.

A nurse is assisting in the care of a client who exhibits manifestations of a major depressive episode. The provider wants to rule out medical conditions that also cause these manifestations. Which of the following medical conditions should the nurse anticipate the provider testing for? A.) Pancreatitis B.) Cholecystitis C.) Tuberculosis D.) Hypothyroidism

D.) Hypothyroidism The expected findings of hypothyroidism, including changes in weight, sleep disturbances, decreased energy, and changes in thought processes, mimic those of a major depressive episode.

A nurse at a mental health facility is discussing antidepressant medications with a newly licensed nurse, comparing selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Which of the following information should the nurse include about TCAs? A.) Less effective in relieving depressive symptoms B.) Low probability of causing sedation C.) More likely to be prescribed as initial treatment D.) Increased risk of cardiovascular adverse effects

D.) Increased risk of cardiovascular adverse effects TCAs can cause cardiac dysrhythmia and can be lethal to the client in the event of overdose. The nurse should include that clients should undergo cardiac screening before beginning therapy and have periodic ECG analysis while taking this medication.

A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include? A.) Requires excessive amount of advice before making decisions B.) Believes his achievements are superior to others C.) Uses physical appearance to make others take notice of him D.) Preoccupied with maintaining order by following rigid rules

D.) Preoccupied with maintaining order by following rigid rules A client who has obsessive-compulsive personality disorder spends most of his time focusing on rules, lists, and details of an activity rather than the actual activity; strives to be perfect, which interferers with completing tasks; and is rigid in his thinking.

A client in a long-term care facility says to the nurse, "I really can't stand my roommate. Is there anything you can do to get me a bed in another room?" When the roommate comes back into the room, the client offers to share the box of cookies her family brought her with the roommate. Which of the following defense mechanisms is the client demonstrating? A.) Denial B.) Displacement C.) Rationalization D.) Reaction formation

D.) Reaction formation The client is demonstrating reaction formation when she overcompensates or demonstrates the opposite behavior of what she feels. By offering cookies to a person she dislikes, she is demonstrating reaction formation.

A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). The client states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse should identify that the client is experiencing which of the following forms of crisis? A.) Adventitious B.) Internal C.) Maturational D.) Situational

D.) Situational A diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular life, such as a serious illness or financial loss.

A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms? A.) Repression B.) Splitting C.) Sublimation D.) Undoing

D.) Undoing The nurse correctly identifies this as an example of denial which is escaping unpleasant or anxiety-causing thoughts or feelings by ignoring their existence.