ATI: Mental Health 8

A nurse is preparing to interview a client who has generalized anxiety disorder. Which of the following actions should the nurse take? A. Set the pace of the interview B. Place the chairs across from each other C. Position the chairs 1.2 m (4 ft) apart D. Maintain an open posture during the interview

Maintain an open posture during the interview *The nurse should be mindful of nonverbal cues such as eye contact, facial expressions, and posture. Maintaining an open posture conveys openness to what the client is saying, while a closed posture with arms crossed can make the client feel defensive

A nurse is collecting data from a client who has a history of methamphetamine use. Which of the following findings indicates that the client is currently under the influence of this drug? A. Paranoia B. Slurred speech C. Marked lethargy D. Bradycardia

Paranoia *Acute effects of methamphetamine use include increased heart rate and metabolism, mental alertness, reduced appetite, and paranoia

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? A. Maintain the client's contact with her family B. Discourage the client's use of vulgar language C. Protect the client from impulsive behavior D. Redirect excessive energy to creative tasks

Protect the client from impulsive behavior *The nurse should protect this client who is manic from impulsive behavior that increases the client's risk of self-harm

A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms? A. Compensation B. Repression C. Regression D. Suppression

Regression *Regression is reverting to a previous, more child-like behavior

A nurse is caring for a client who has generalized anxiety disorder. The client states, "I am so stressed about my work and finances. I can't think straight anymore." Which of the following actions should the nurse take first? A. Administer antianxiety medication B. Speak slowly and calmly C. Remain with the client D. Ask the client to talk about preceding events

Remain with the client *The greatest risk to this client is an injury from anxiety and distress, which can cause the client to lose control. Therefore, the nurse should remain with the client to convey acceptance and promote security

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol? A. Akathisia B. Acute dystonia C. Tardive dyskinesia D. Pseudoparkinsonism

Tardive dyskinesia *The nurse should identify that tardive dyskinesia can be manifested by involuntary movement of many body parts. Early findings include writhing movements of the tongue and smacking of the lips. The nurse should report these findings to the provider immediately because they might not be reversible and can progress to affect all extremities with rhythmic, uncontrollable writhing movements

A nurse is caring for a client who was voluntarily admitted to an inpatient mental health facility for treatment of major depressive disorder. After consenting to deep brain stimulation, the client tells the nurse he does not want to have the procedure. Which of the following actions should the nurse take? A. Explain that the provider is highly proficient in this therapy B. Tell the client that he has the right to refuse the procedure C. Explain that deep brain stimulation is a promising therapy for major depression D. Remind the client that agreeing to admission means the provider can proceed with the treatment

Tell the client that he has the right to refuse the procedure *Unless the client is a danger to himself or others, he has the right to refuse treatment, even after signing an informed consent form. The nurse should notify the provider to cancel the procedure

A nurse is discussing the benefits of group therapy with a client who has bipolar disorder. The nurse should identify which of the following as an advantage of this form of treatment? A. Decreased pressure from others to engage in unacceptable behaviors B. The chance to learn from the experiences of other individuals C. An outlet for increased energy during episodes of mania D. The opportunity to have increased participation time during therapy

The chance to learn from the experiences of other individuals *The nurse should identify the opportunity to learn and gain insight from other group members as an advantage of group therapy

A nurse is admitting a client who has derealization disorder. Which of the following manifestations should the nurse expect? A. The inability to recall important personal information B. The feeling that the surroundings are unreal C. The inability to recall identity D. The presence of at least 2 distinct personalities

The feeling that the surroundings are unreal *The feeling that the surroundings are unreal or distant is a manifestation of derealization disorder. Clients who have this disorder might feel mechanical, dreamy, or detached from their body. Often, the manifestations are destressing and come and go. The disorder occurs as a response to acute stress

A nurse is collecting data from an adult client whose sister recently died in a motor vehicle crash. The nurse should identify that which of the following factors indicates an increased risk for a complicated grief reaction? A. The loss of a sibling B. The perception that the death was unavoidable C. The sudden occurrence of the death D. The presence of a social support network

The sudden occurrence of the death *A sudden, unanticipated death can complicate the mourning process and lead to a complicated grief reaction. Other factors include death from a lengthy illness, the loss of a child, or the perception that the death was preventable

A nurse is caring for a client who has a repetitive tic that is accompanied by rapid blinking. The client occasionally repeats phrases spoken by others. The nurse should identify that these findings are an indication of which of the following disorders? A. Autism spectrum disorder B. Attention deficit hyperactivity disorder C. Oppositional defiant disorder D. Tourette's disorder

Tourette's disorder *The nurse should suspect that this client has Tourette's disorder, which can include more than 1 motor tic along with vocal tics (e.g. repeating phrases of others or barking.)

A nurse is reinforcing dietary teaching with a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which of the following food selections by the client indicates an understanding of the teaching? A. Cheddar cheese B. Avocados C. Pepperoni D. Yogurt

Yogurt *Yogurt does not contain high amounts of tyramine and is allowed for clients who are taking an MAOI medication

A nurse is reinforcing teaching with a client who has a new prescription for buspirone to treat anxiety. Which of the following statements should the nurse include in the teaching? A. "Use buspirone with caution because it raises the risk of suicidal thoughts." B. "You can minimize adverse effects by taking buspirone with grapefruit juice." C. "Buspirone enhances the depressant effects of alcohol." D. "Buspirone causes nausea in some people."

"Buspirone causes nausea in some people." *Adverse effects of buspirone include nausea, dizziness, headaches, nervousness, sedation, lightheadedness, and excitement

A nurse in a mental health clinic is working with a client whose partner recently started working overseas. The client states, "My youngest child is having difficulty coping with my partner's absence." Which of the following responses should the nurse offer? A. "You should administer punishment if your child acts out." B. "Continue to do the activities that your family did before your partner's absence." C. "You child should see a counselor if he doesn't adjust to your partner's absence within 2 weeks." D. "Give your child the opportunity to spend as much time alone as he needs"

"Continue to do the activities that your family did before your partner's absence." *The nurse should instruct the client to continue usually family activities from before the partner's absence and to encourage the child to resume his usual activities. Returning to familiar activities can help re-establish a sense of normalcy for the family

A nurse is participating with a disaster-support team following a tornado. When collecting data from a client who was affected by the tornado, which of the following questions should the nurse ask the client first? A. "Do you feel safe now that the tornado is gone?" B. "What do you think about the tornado?" C. "Do you have anyone you can contact for support?" D. "How do you usually cope with difficult situations?"

"Do you feel safe now that the tornado is gone?" *When using Maslow's hierarchy of needs, the nurse's priority is to determine if the client has a sense of safety

A client recently diagnosed with terminal cancer states to the nurse, "I wish I were dead. I have no reason to live." Which of the following responses should the nurse offer? A. "You still have a lot to live for." B. "Please don't talk about that." C. "Your prescribed medication will make you feel better." D. "Have you been thinking of hurting yourself."

"Have you been thinking of hurting yourself." *The nurse's response focuses on the client's underlying feelings and begins to examine the obvious verbal clues of suicidal thoughts. Asking the client about suicidal thoughts is an important intervention by the nurse because if the client is contemplating suicide, the client should be able to discuss these feelings with the nurse

A nurse in a clinic is collecting data from a client who asks for help with depression. Which of the following questions is the nurse's priority? A. "Is there anything in particular that makes you feel angry?" B. "Have you had difficulty falling asleep or staying asleep?" C. "Have you thought about harming yourself in any way?" D. "Do you have someone you can talk with at home?"

"Have you thought about harming yourself in any way?" *The greatest risk to this client is an injury from self-harm; therefore, the nurse's priority is to determine whether the client is at risk by asking about thoughts of self-harm or a suicide plan

A nurse is collecting data from a client who has major depressive disorder regarding suicide risk factors and protective factors. Which of the following client statements should the nurse identify as a protective factor that decreases the client's risk for suicide? A. "I am a college graduate and make a lot of money at my profession." B. "I consider myself a good problem solver." C. "My family lives out-of-state, and I spend my spare time at home." D. "I enjoy restoring antique weapons and have a nice collection."

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

A nurse is talking with a client who has anxiety disorder. The client states, "I have something important to tell you, but you have to promise to keep it a secret." Which of the following responses should the nurse make? A. "Anything you tell me is kept private between us." B. "I feel uncomfortable being asked to keep a secret for you." C. "Why do you feel that the information needs to be kept private?" D. "I might have to share the information with your provider."

"I might have to share the information with your provider." *The nurse should be honest with the client so that the client can decide whether to share the information. The information the client shares can be vital for the treatment plan and can present a safety risk for the client or others. Therefore, the nurse might be legally obligated to share the information with the client's provider and health care team

A nurse is caring for a client who has antisocial personality disorder. The client uses manipulation to gain access to a smoking area from which his access has been limited as a behavioral intervention. Which of the following statements should the nurse make? A. "You know you shouldn't use the smoking area." B. "You know that manipulation is not the right thing to do." C. "Let's review the consequences of your actions." D. "I can talk with the provider about reducing your smoking restriction."

"Let's review the consequences of your actions." *When communicating with a client who has antisocial personality disorder, the nurse should set clear and realistic limits on behavior that all staff members adhere to, identify the client's undesirable behavior, and communicate the consequences of that behavior

A nurse in a long-term mental health facility is caring for a client who has a personality disorder. Because the client has broken a unit rule, phone privileges are being revoked. The client asks the nurse, "Can't I just make another phone call?" Which of the following responses should the nurse make? A. "No, you can't. Go sit in your room." B. "Okay, if you promise to obey the rules for the rest of the day." C. "No, you can't. You have broken the rules that apply to everyone." D. "You can make only a 5-minute phone call."

"No, you can't. You have broken the rules that apply to everyone." *The nurse's response correctly enforces unit rules, identifies the reason for the consequence, and decreases the likelihood of future manipulative behavior

A nurse is assisting a client who has major depressive disorder. The client states, "This has been the worst day of my life." Which of the following responses should the nurse make? A. "You should focus on positive things rather than negative things." B. "We all have a bad day from time to time." C. "Why would someone with so much to live for say that?" D. "Please take a seat and talk to me about it."

"Please take a seat and talk to me about it." *This response by the nurse is therapeutic and encourages the client to talk about his feelings and what might have caused them. This helps the nurse develop a trusting relationship with the client, in which the client will feel safe opening up to the nurse. Using therapeutic communication techniques helps to identify the client's specific needs and problems, which can lead to a solution

A nurse is caring for a client who is confused and wanders at night. The nurse asks the charge nurse if the client can be placed in physical restraints at bedtime. Which of the following responses should the charge nurse provide? A. "Restraints can be used if the client is having verbal outbursts." B. "Restraints have been effective in reducing the number of client falls." C. "Restraints can used only when the unit manager approves." D. "Restraining the client can increase confusion."

"Restraining the client can increase confusion." *Restraining a confused client can worsen confusion. The nurse should use other methods to prevent wandering such as suggesting diversional activities, reducing stimulation, and administering a PRN medication

A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make? A. "Aliens do not exist." B. "Has your daughter had her baby?" C. "Do you mean to say a laboratory technician drew your blood last night?" D. "That does not sound real."

"That does not sound real." *The nurse is voicing doubt with this response, which expresses uncertainty regarding the reality of the client's conclusion of the hallucination. This is a therapeutic response because the statement allows the client to expand upon the earlier statement, which allows exploration of the client's thought processes

A nurse in a health clinic is reinforcing teaching with a client about binge eating disorder. Which of the following client statements indicates an understanding of the teaching? A. "This problem is caused by a slow metabolism." B. "The abdominal pain I often have is due to the amount of food that I eat." C. "Most of my weight gain is water weight." D. "At least I do not need to worry about being physically ill."

"The abdominal pain I often have is due to the amount of food that I eat." *Gastrointestinal complications can arise for clients who have binge eating disorder due to the larger than normal amount of food they consume. Other manifestations include constipation, diarrhea, urgency, and a feeling of anal blockage

A nurse is reinforcing teaching with the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by a family member indicates an understanding of ECT? A. "We are so glad there are no physical side effects of shock treatment." B. "Thank goodness there is no permanent memory loss." C. "Cardiac dysrhythmias can persist for several weeks." D. "We won't be alarmed if there is some confusion after the treatment."

"We won't be alarmed if there is some confusion after the treatment." *It is common following ECT for a client to experience confusion and disorientation

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client informs the nurse, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? A. "That is silly. You look just fine to me." B. "Nobody expects you to look good in a hospital." C. "I understand. Would you like to wash your hair?" D. "Would you like to talk about why you feel this way?"

"Would you like to talk about why you feel this way?" *This response by the nurse acknowledges the client's feelings and conveys the ability to understand them, which promotes a trusting relationship between the client and the nurse

A nurse on a psychiatric unit is talking with a client who makes a sexual advance toward the nurse. Which of the following responses should the nurse provide? A. "It's normal for you to have sexual feelings toward the staff." B. "You need to stop any type of sexual advances." C. "This behavior is unacceptable while I am your nurse." D. "What would your family think of this type of behavior?"

"You need to stop any type of sexual advances." *The nurse should clearly identify behavior expectations to help promote and maintain appropriate boundaries

A nurse is collecting data from a client who has been using a nicotine transdermal patch for smoking cessation. The client reports itching of the skin where the patch is applied. Which of the following statements should the nurse make? A. "You should change the location of the patch on your body." B. "Decreasing the strength of the patch should stop the itching." C. "You should discontinue using the patch." D. "This is an adverse effect of the patch that will subside in time."

"You should discontinue using the patch." *The nurse should instruct the client to discontinue the patch if persistent local reactions such as erythema, itching, or edema is experienced

A nurse is reinforcing discharge teaching with the guardians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as an indication of acute mania? (select all that apply) A. Complete school projects B. Naps during the daytime C. Eats large amounts D. Spends excessive amounts of money E. Speaks using a loud and crass voice

1. Spends excessive amounts of money 2. Speaks using a loud and crass voice *A client who has acute mania is impulsive and at risk of spending excessive amounts of money despite financial status. Additionally, a client who has acute mania has rapid speech and quick thoughts; other alterations in speech include speech that is vulgar or sexually explicit

A nurse is assisting with the collection of admission data for a client who has anorexia nervosa. The client has lost 11.4 kg (25 lb) over the past month and currently weights 38.6 kg (85 lb). The nurse should expect which of the following findings? A. Flushed extremities B. Hyperkalemia C. Loose stools D. Amenorrhea

Amenorrhea *The nurse should expect this client who has anorexia nervosa to have amenorrhea due to low body weight

A nurse in an acute substance disorder unit is collecting data from a client who received treatment in the emergency department for an opioid overdose. Which of the following findings should the nurse anticipate during opioid withdrawal? A. Calmness B. Anxiety C. Hypotension D. Bradycardia

Anxiety *The nurse should expect the client to have anxiety during opioid withdrawal

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? A. Apply mechanical restraints to the client B. Administer PRN haloperidol IM to the client C. Approach the client in a nonthreatening manner D. Place the client in seclusion

Approach the client in a nonthreatening manner *The first action the nurse should take is to approach the client calmly to create a nonthreatening environment.

A nurse is caring for a client who has cirrhosis of the liver due to alcohol use disorder. Which oft he following findings should the nurse expect? A. Acrocyanosis B. Arrhythmias C. Ascites D. Weight gain

Ascites *The nurse should expect this client who has cirrhosis of the liver to exhibit gastrointestinal and hepatic manifestations due to the destruction of liver cells. Ascites results from the accumulation of serous fluid in the abdominal cavity due to portal hypertension. Jaundice, weight loss, and esophageal varices are other expected findings of this disorder

A nurse is caring for a client who has schizophrenia and is becoming anxious due to auditory hallucinations. Which of the following actions should the nurse take? A. Offer the client therapeutic touch B. Ask the client what he is hearing C. Affirm the presence of the voices D. Move the client into a more stimulating environment

Ask the client what he is hearing *The nurse should ask the client about what he is hearing to determine if the hallucination is causing fear or distress to the client. Also, the nurse needs to determine if the hallucination may cause the client to harm himself or others. However, asking the client, "What are the voices saying to you?" can infer that the nurse believes the voices are real

A nurse is caring for a client who has newly diagnosed with breast cancer that has metastasized in to the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kubler-Ross' grief theory? A. Anger B. Bargaining C. Denial D. Depression

Denial *During the first stage, denial and refusal to accept the imminence of the loss are self-protection mechanisms that allow the client to process the diagnosis. During this stage, the client has difficulty accepting the loss or diagnosis and might refuse to discuss the impending or actual loss during this stage. The client might also be convinced that a mistake has been made and that there is no loss

A nurse in a community urgent care facility is helping plan interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis

Determine if the client is experiencing thoughts of self-harm *The nurse should determine whether the client has thoughts of self-harm following a sexual assault or other crisis situations. The nurse's priority is to ensure the client's safety.

A nurse is assisting with the admission of a client who has alcohol use disorder and is experiencing withdrawal. Which of the following actions is the nurse's priority? A. Pad the side rails of the client's bed B. Assign the client to a private room C. Collect a urine sample from the client D. Determine the client's level of disorientation

Determine the client's level of disorientation *The greatest risk to this client is self-injury from the alcohol withdrawal; therefore, the priority action the nurse should take is to determine the client's level of disorientation to ensure the client is safe from self-injury or harm

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

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

A nurse is reinforcing teaching with a client who has a prescription for lithium. Which of the following instructions should the nurse include in the teaching? A. Take this medication on an empty stomach B. Drink 2 L of fluid each day C. Use a salt substitute to season foods D. Take ibuprofen for headaches

Drink 2 L of fluid each day *The nurse should instruct the client to drink at least 2 to 3 L of fluid per day to remain hydrated and to consume a consistent amount of sodium. Low sodium levels can result in lithium toxicity

A nurse is assisting with planning care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects? A. Hypertension B. Drowsiness C. Panic attacks D. Diarrhea

Drowsiness *Drowsiness is an expected side effect of amitriptyline and other tricyclic antidepressants. Sedation will likely be present during the first few weeks of treatment with amitriptyline and put the client at risk for falls

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. Blurred vision B. Urinary retention C. Muscle flaccidity D. Elevated temperature

Elevated temperature *Elevated temperature is a manifestation of neuroleptic malignant syndrome that should be immediately reported to the provider. Other symptoms of the syndrome include rigidity, sweating, dysrhythmias, and fluctuations in blood pressure

A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include to address limit-setting? A. Instruct the client to use reaction formation for behavior control B. Recommend the client attend assertiveness training C. Establish and explain consequences of the client's behavior D. Encourage the client to increase socialization

Establish and explain consequences of the client's behavior *The nurse should communicate desired behavior and expectations to the client, as well as the detailed consequences of not meeting them. When addressing limit-setting with the client, these expectations and consequences should be included in the plan of care

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of playing staff members against each other. Which of the following actions should the nurse take? A. Have the same staff members work with the client on a long-term basis B. Listen to the client when he reports feelings about other staff members C. Explore the client's use of clinging and distancing behaviors with him D. Arrange for the client to share complaints with the nursing supervisor

Explore the client's use of clinging and distancing behaviors with him *Splitting is a common defense mechanism demonstrated by clients who have BPD in which the client plays staff members against each other. First, the client expresses feelings of attachment toward a certain staff member and then abruptly begins issuing complaints about this person to other staff members. The underlying cause of splitting is a fear of abandonment and an inability to accept both positive and negative feelings. Therefore, the client demonstrates only negative or positive feelings toward others

A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following actions should the nurse nurse include in the plan of care? A. Avoid making eye contact with the child B. Rotate staff assignments for the child C. Offer frequent acts of physical affection towards the child D. Give the child a favorite toy to hold

Give the child a favorite toy to hold *The nurse should provide the child with a familiar object such as a favorite toy or a blanket to foster a sense of comfort and security

A nurse is collecting data from a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? A. Calling family members B. Spending time alone C. Giving away possessions D. Excessive crying

Giving away possessions *Giving away possessions indicates that this adolescent client is a the greatest risk for suicide. The nurse should have a relationship built on trust an respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. Therefore, this is the priority finding for the nurse to report to the treatment team

A nurse is caring for a client who has bipolar disorder. Which of the following manifestations is the priority finding for the nurse to identify? A. Inability to concentrate B. Poor hygiene C. Hyperactivity D. Pressured speech

Hyperactivity *The greatest risk to this client is an injury from hyperactivity; therefore, the priority finding for the nurse to identify is hyperactivity. The nurse should intervene to redirect the client from unsafe activities. Constant activity can lead to exhaustion and even death

A client who has hypertension presents to a provider's office. When speaking with the nurse, she reports a considerable amount of stress at work and states it is affecting her blood-pressure control. The nurse should instruct the client to do which of the following when the stress is unavoidable? A. Consider changing jobs to something less stressful B. Identify the stressors at work and try to reduce them C. Plan periods away from work throughout the day D. Improve her ability to cope with identified stressors

Improve her ability to cope with identified stressors *The nurse should help the client learn management techniques to deal with stress without internalizing it

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? A. Low body temperature B. Insomnia C. Muscle flaccidity D. Bradycardia

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

A nurse is reinforcing teaching with a client who has a new prescription for bupropion. The nurse should instruct the client to report which of the following findings as an adverse effect of bupropion? A. Hypotension B. Blurred vision C. Tinnitus D. Insomnia

Insomnia *The nurse should instruct the client to report insomnia, which is an adverse effect of bupropion. Other adverse effects can include anxiety, delusions, hypertension, dry mouth, nausea, weight loss or gain, and photosensitivity

A home health nurse is reinforcing teaching for the family who has moderate Alzheimer's disease. The family plans to care for the client in their home. Which of the following recommendations should the nurse include in the teaching? A. Place nonskid throw rugs over smooth surface floors B. Install locks at the top of exterior doors C. Provide clothing that has zippers instead of buttons D. Encourage frequent naps during the day

Install locks at the top of exterior doors *This client is at an increased risk of wandering and getting lost. A safety intervention to decrease the risk of wandering is to install locks at the tops of exterior doors since a client who has moderate Alzheimer's disease loses the ability to reach and look upward

A nurse is assisting with planning an in-service session about involuntarily commitment to mental health facilities for a group of newly licensed nurses. Which of the following pieces of information should the nurse recommend including? A. The client can challenge hospitalization following emergency treatment B. Involuntarily commitment requires the hospitalization of the client C. A client who is competent but committed involuntarily is unable to make treatment decisions D. Court hearings should be held 7 days after emergency commitment

Involuntarily commitment requires the hospitalization of the client *A client can be court-ordered to undergo outpatient psychiatric treatment as well as inpatient treatment. Involuntary outpatient treatment is used most often for clients who have severe and chronic mental illness in order to limit the need for inpatient admissions for the client

A nurse in a mental health facility is assisting with the care of a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit? A. Lack of remorse B. Self-mutilation C. Delusional behavior D. Splitting

Lack of remorse *A client who has antisocial personality disorder lacks empathy for others and shows no remorse of guilt for callous behavior