ATI: Mental Health 3

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired, is an important part of your treatment." B. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." D. "I agree with your decision to wait for participation in group therapy until you begin to feel better."

"Attending group therapy, even if you're tired, is an important part of your treatment." *Through this therapeutic response, the nurse is giving the client information to make an informed decision. Group therapy benefits clients who have depression by promoting peer support and reducing social isolation

A nurse is discussing family therapy with a client. Which of the following statements by the nurse is therapeutic? A. "Family therapy helped my family." B. "I need to sign you up for family therapy." C. "Family therapy can bring about change." D. "Why do you think you need family therapy?"

"Family therapy can bring about change." *The nurse is using the therapeutic communication technique of providing information. By explaining what family therapy can offer, the nurse can empower the client to make a better decision about whether to pursue such therapy

A nurse is reinforcing teaching with the partner of a client who has alcohol use disorder. Which of the following statements by the partner indicates an understanding of the teaching? A. "Having 6 beers in 2 hours is considered too much." B. "My partner is not at risk for cancer due to alcohol consumption." C. "My partner should consume no more than 20 drinks of alcohol in a week." D. "There is no genetic risk with abuse alcohol."

"Having 6 beers in 2 hours is considered too much." *Binge drinking refers to drinking too much alcohol in a short amount of time, causing the blood alcohol level to rise. This usually occurs with 5 or more drinks for males and 4 or more drinks for females within 2 hours

A nurse is leading a group therapy session for a group of clients. Which of the following client statements should indicate to the nurse that the client is using the defense mechanism of rationalization? A. "I became a team manager because I'm not tall enough to succeed at basketball." B. "I don't want to talk right now about the fire that destroyed my home." C. "I take amphetamines because it's the only way I can keep up with all the studying for my classes." D. "I will spend a day cleaning my house when I feel like my life is out of control."

"I take amphetamines because it's the only way I can keep up with all the studying for my classes." *Rationalization is the act of justifying unacceptable thoughts or behaviors with a seemingly acceptable explanation. Rationalization allows the client to protect the ego and avoid taking responsibility for actions or thoughts that can cause shame of embarrassment

A nurse is reinforcing teaching with the parents of a school-aged child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? A. "Ignore your child's attention-seeking behaviors that are not dangerous." B. "Administer ADHD medications within 30 min of your child's bedtime." C. "Continue with an activity as planned even if your child becomes frustrated." D. "Expect your child to gain weight after starting ADHD medications."

"Ignore your child's attention-seeking behaviors that are not dangerous." *The nurse should instruct the parents about the use of planned ignoring. This technique ignores attention-seeking behaviors that are not dangerous to the child or others. If the child learns that the behavior will not elicit the desired response, then the behavior should decrease

A nurse is reinforcing teaching with the caregiver of a child who has pica. Which of the following statements should the nurse identify as an indication that the caregiver understands the teaching? A. "My child will have this disorder for the rest of his life. B. "My child will return undigested food to his mouth because of this disorder." C. "My child might try to eat dirt when we are at the playground." D. "My child will need to be repositioned during feedings."

"My child might try to eat dirt when we are at the playground." *Pica is the persistent eating of non-food substances that have no nutritional value such as dirt or paint

A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement? A. "I smoked for years, but now I cannot stand to be around cigarette smoke." B. "I didn't get the promotion at work because my boss hates me." C. "My partner yelled at me, so I made the cat go outdoors." D. "I won't worry about losing my job until my child's break from school is over."

"My partner yelled at me, so I made the cat go outdoors." *This statement is consistent with the use of displacement. Displacement is the transference of emotions associated with a person, object, or situation to another non-threatening person, object, or situation.

A nurse in a rehabilitation center for clients with substance use disorders is collecting data from a client who is being admitted. The client tells the nurse, "I am afraid of other people finding out that I am in a rehabilitation center." Which of the following responses should the nurse make? A. "You don't need to worry about that." B. "You should be proud of yourself for getting treatment." C. "Why do you care what other people think?" D. "Tell me more about how you are feeling about being here."

"Tell me more about how you are feeling about being here." *The nurse is using therapeutic communication by exploring the client's feelings and encouraging the client to discuss them.

A nurse is reinforcing teaching about decreasing codependent behaviors with the family of a client who has alcohol use disorder. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will help her financially if she loses her job." B. "We will not hold her responsible for her alcohol use." C. "We will routinely search for and remove any alcohol in her home." D. "We will not let our moods be changed by her behavior."

"We will not let our moods be changed by her behavior." *The nurse should explain to the family that alcohol use is self-inflicted and that the client must take responsibility for her actions. The family should not allow the client's dysfunctional behavior to control their environment. Establishing boundaries with the client is the family's first step in reducing the codependent behaviors

A nurse is collecting data from a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A. "I thought I hear something too." B. "Is someone telling you something?" C. "What are you hearing?" D. "There is nobody in that chair for you to listen to."

"What are you hearing?" *This open-ended question allows the nurse to find out what the client is hearing without validating the hallucination as real. The nurse should watch the client for anxiety or fear and ensure that the hallucination is not commanding the client to hurt self or others. After an assessment of the client's hallucinations is complete, the nurse can develop a plan to decrease the hallucinations.

A nurse is preparing to administer lurasidone 80 mg PO daily to a client. Lurasidone is available as 40 mg tablets. How many tablets should the nurse administer?

2 tablets

A nurse is providing teaching to a client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make?

A. "Feelings of sedation should resolve in about 1 week."

A nurse is providing teaching to the parents of a school-age child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following instructions should the nurse include in the teaching?

A. "Ignore your child's attention-seeking behaviors that are not dangerous."

A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of the following findings should the nurse expect?

A. Restlessness

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

A. The client is experiencing mild acetaldehyde syndrome

A nurse is caring for an adult client who has alcohol use disorder. The client states she is refusing further treatment and is leaving the mental health facility. Which of the following actions should the nurse take? A. Request a prescription for restraints from the provider B. Notify security and ask them to lock the unit's exit doors C. Notify the client's family of her intent to leave D. Ask the client to sign an against medical advice form

Ask the client to sign an against medical advice form *The client has the right to refuse treatment and leave the mental health facility unless involuntarily committed. The nurse should ask the client to sign an against medical advice (AMA) form stating that she is choosing to leave the facility against the recommendation of her provider

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A. Assertive community treatment B. Supportive group C. Private counseling D. Vocational rehabilitation services

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

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

C. Xerostomia this is known as dry mouth. Other adverse effects include headache, nausea and insomnia, mylagia, blurry vision and tachycardia

A nurse is caring for a client who has anorexia nervosa. The client states, "If I gain weight, I'll never get a boyfriend." Which of the following cognitive distortions is the client displaying? A. Overgeneralization B. Personalization C. Emotional reasoning D. Catastrophizing

Catastrophizing *A client displays the cognitive distortion of catastrophizing by assuming the worst possible outcomes will occur

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse prepare to administer?

D. Lorazepam

A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medication should the nurse expect the provider to prescribe to assist the client in maintaining sobriety? A. Varenicline B. Clonidine C. Buprenorphone D. Disulfiram

Disulfiram *Disulfiram is a type of aversion therapy that helps clients abstain from alcohol. Drinking alcohol while taking this medication produces a toxic reaction that causes swelling, confusion, headaches, breathing difficulties, and other manifestations

A nurse is reinforcing teaching for a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which of the following manifestations is an adverse effect of this medication? A. Oliguria B. Tinnitus C. Dizziness D. Insomnia

Dizziness *The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined

A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of bipolar disorder. Which of the following behaviors should the nurse describe as a trigger for a relapse of mania? A. Using a daily planner B. Sleeping too much C. Eating too much protein D. Drinking alcohol

Drinking alcohol *The use of alcohol, caffeine, some over-the-counter medications, and some substances can trigger a relapse

A nurse is reviewing the laboratory report of a client who is taking risperidone. The nurse should identify that which of the following result indicates a potential adverse reaction to the medication? A. Elevated blood glucose B. Elevated WBC count C. Decreased platelet count D. Decreased aspartate transaminase (AST)

Elevated blood glucose *The nurse should identify that all second-generation antipsychotic medications such as risperidone can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. If there is no change after 12 weeks, glucose should be monitored annually

A nurse is planning care for a client who has dissociative disorder and is experiencing flashbacks while in public. Which of the following interventions should the nurse include in the plan to help the client recognize and counter the flashbacks? A. Encourage reality testing B. Provide opportunities for socialization C. Consistently remind the client of past traumatic events D. Discourage client expressions of negative feelings

Encourage reality testing *Reality testing involves scanning the surrounding to see if others are afraid and reorientations to time and place. This can help clients recognize that the flashbacks are not real

A nurse is assisting with preparing an in-service session about Alzheimer's disease for a group of newly licensed nurses. Which of the following findings should the nurse include as an early manifestation in the progression of the disease? A. Forgetting material that was just read B. Losing the ability to feel emotions C. Experiencing changes in physical abilities such as swallowing D. Having difficulty controlling the bladder

Forgetting material that was just read *Forgetting material that has just been read is a sign of mild Alzheimer's and is an early manifestation of the disease. Mild memory impairment includes recent memory. Gradually, deterioration progresses to include both recent and remote memory

A nurse on an inpatient mental health unit is caring for a client who is angry and showing signs of potential violence. Which of the following actions should the nurse take to de-escalate the client's anger? A. Call security personnel for a show of force B. Inform the client that restraints will be used as a consequence for verbal abuse C. Speak to the client in a loud, forceful voice D. Give the client extra personal space

Give the client extra personal space *A client who is experiencing escalating anger requires additional space to feel less threatened. The nurse should stand 1 foot farther away from the client than the client's arms and legs can reach

A nurse is collecting data from a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? A. Decreased appetite B. Slurred speech C. Insomnia D. Hallucinations

Hallucinations *Hallucinations are a manifestation of severe alcohol withdrawal. Other manifestations of severe alcohol withdrawal include diaphoresis, hyperthermia, and tachycardia

A nurse in a mental health facility is planning to promote the development of a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take? A. Begin each interaction by sharing a personal story B. Identify professional boundaries during the initial interaction C. Agree with the client's perceptions and emotions to encourage free expression D. Allow the client to meet with the nurse at any time during the day

Identify professional boundaries during the initial interaction *The nurse should promote a therapeutic nurse-client relationship by identifying distinct boundaries with the client. These boundaries help promote a therapeutic nurse-client relationship, rather than a social nurse-client relationship

A nurse is collecting data from a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline? A. Disorientation to time B. Problems handling finances C. Social withdrawal D. Impaired recent memory

Impaired recent memory *Short-term memory loss is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality

A nurse is contributing to the plan of care for a client who has borderline personality disorder and self-mutilates. Which of the following treatment approaches should the nurse recommend? A. Restrict participation in group therapy sessions B. Establish consequences for self-mutilation C. Maintain close observation of the client D. Provide an unstructured environment

Maintain close observation of the client *Clients who have borderline personality disorder are at risk of self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury

A nurse in a rehabilitation center is planning to reinforce medication teaching with a client who is being discharged following treatment for opioid use disorder. Which of the following medications should then nurse expect the provider to prescribe for the client? A. Diazepam B. Disulfiram C. Bupropion D. Methadone

Methadone *Methadone is used to decrease symptoms during the withdrawal phase of opioids. It is also used following withdrawal for maintenance therapy, as methadone decreases the euphoric effects of opiate drugs. Methadone can also lead to dependence, and the client will eventually need to be withdrawn from the medication

A nurse is caring for a client at a college mental health counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms?

Projection

A nurse is caring for a client with ADHD who has recently started taking lithium. For which of the following findings should the nurse monitor when evaluating the effectiveness of the medication? A. Increased attention span B. Decreased anxiety C. Reduced aggression D. Weight loss

Reduced aggression *Clients who have ADHD can experience a low tolerance for frustration, which can result in aggressive behaviors. Although psychosocial interventions should include developing coping mechanisms and cognitive behavior therapy, the client might require medication to manage aggressive behaviors. The nurse should monitor for reduced aggression when a client who has ADHD is taking a mood stabilizer such as lithium. Additional outcomes of mood-stabilizing medications include decreased impulsivity

A nurse at an acute care facility is assisting with the care of a client who is receiving IV antibiotic treatments for an infection. The client reported daily alcohol use at home. On the seconds day of admission, the client becomes agitated, hypertensive, and tachycardic. Which of the following actions should the nurse plan to take? A. Administer methadone when agitation increases B. Administer zolpidem before meals C. Request a prescription for a different antibiotic D. Request a prescription for chlordiazepoxide

Request a prescription for chlordiazepoxide *The nurse should recognize these findings as indications of withdrawal from alcohol and should intervene to decrease adverse manifestations. Chlordiazepoxide, an anxiolytic, is a benzodiazepine prescribed for alcohol withdrawal that reduces manifestation and can help prevent seizures and delirium tremens

A nurse in the emergency department is assessing a client with heroin intoxication. Which of the following findings should the nurse expect?

Respiratory depression

A nurse on an inpatient rehabilitation unit is assessing a client who has a history of opioid use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect? A. Hyperactivity B. Headache C. Rhinorrhea D. Tremulousness

Rhinorrhea *Rhinorrhea, lacrimation, pupillary dilation, yawning, and piloerection are classic manifestations of opioid withdrawal

A nurse is providing teaching to a client who has panic disorder and a new prescription for clomipramine. Which of the following adverse effects should the nurse include in the teaching?

Sedation

A nurse is collecting dat from a school-aged child who has ADHD and has been taking desipramine. Which of the following adverse effects should the nurse expect the child's parent to report? A. Hyperactivity B. Depression C. Diarrhea D. Sedation

Sedation *The nurse should recognize that tryicyclic antidepressants can cause sedation, along with other anticholinergic effects. Therefore, the nurse should expect the parent to report that the child has been sedated

A nurse is caring for a client who requests information about smoking cessation using nicotine gum. For which of the following reasons should the nurse recommend another over-the-counter smoking cessation product to the client? A. The client is overweight B. The client follows a vegan diet C. The client has dentures D. The client has insomnia

The client has dentures *The nurse should explain to the client that nicotine gum is difficult for clients who wear dentures to use and that using the gum can damage dental work. The nurse should recommend the nicotine patch or nicotine lozenges as an over-the counter alternative

A nurse is caring for a client who has post-traumatic stress disorder (PTSD) and who is undergoing eye movement desensitization and reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies? A. Exposes the client to circumstances that trigger the PTSD B. Assists the client with behavioral modification C. Encourages the client to visualize a relaxing scene when traumatic memories occur D. Uses stimuli to change how the client processes the trauma

Uses stimuli to change how the client processes the trauma *EMDR uses stimuli such as tapping, eye movements, or audio sounds combined with verbalization of the traumatic event by the client. While the client recalls the traumatic event, these stimuli create neurological and physiological changes in how the client integrates the memories. EMDR is a type of psychotherapy carried out during several sessions by a therapist who is trained in the method

a nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone the nurse should inform the client that which of the following manifestations is common adverse effect of this medication

dizziness The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined.

a nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder the client tells the nurse I have not had anything to drink for 6 hours which of the following findings should the nurse expect during alcohol withdrawal

insomnia The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia and restlessness.

a nurse is providing teaching to a client who has a new prescription for disulfiram for management of alcohol dependence which of the following dietary choices should the nurse instruct the client to avoid

pure vanilla extract The nurse should instruct the client to avoid alcohol and alcohol-containing substances, such as pure vanilla extract, while taking disulfiram. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension