ATI MENTAL HEALTH Practice A
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? "I put in extra hours at work so I won't think about drinking." "I know that wine is good for my heart, so that's why I drink some each evening." "I make up for my drinking by taking my partner on nice vacations." "I am able to go to work every day, so I don't have a problem."
"I am able to go to work every day, so I don't have a problem." By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder. "I put in extra hours at work so I won't think about drinking." A client who consciously avoids thinking about uncomfortable feelings or thoughts is using the defense mechanism of suppression. "I know that wine is good for my heart, so that's why I drink some each evening." By relating their drinking every evening to their heart health, the client is using the defense mechanism of rationalization. "I make up for my drinking by taking my partner on nice vacations." A client who attempts to make up for an undesirable act by doing something positive is using the defense mechanism of undoing.
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief? "I wish I had been nicer and more generous with my wife before she died." "I told my wife to go to the doctor, but she wouldn't listen to me." "I think about my wife all the time when I go on outings with my family." "I feel so empty without my wife that it's hard to get up every morning."
"I feel so empty without my wife that it's hard to get up every morning." The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief. "I wish I had been nicer and more generous with my wife before she died." The nurse should identify that the client is expressing guilt, which is an expected finding of grief. "I told my wife to go to the doctor, but she wouldn't listen to me." The nurse should identify that the client is expressing anger, which is an expected finding of grief. "I think about my wife all the time when I go on outings with my family." The nurse should identify that the client is expressing preoccupation with the deceased, which is an expected finding of grief.
A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? "I should eat a regular diet with normal amounts of salt and fluids." "I should discontinue the lithium when I begin to feel better." "I need to be careful to avoid becoming addicted to the lithium." "I can skip a dose of medication if my stomach is upset."
"I should eat a regular diet with normal amounts of salt and fluids." The nurse should identify that this statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. "I should discontinue the lithium when I begin to feel better." The nurse should identify that bipolar disorder is a chronic illness and is not cured with medication. The client should continue taking lithium after manifestations improve to prevent future relapse. "I need to be careful to avoid becoming addicted to the lithium." The nurse should identify that lithium is indicated for the continued treatment of bipolar disorder. Lithium does not cause physical dependency or addiction. "I can skip a dose of medication if my stomach is upset." The nurse should identify that taking lithium with a meal can decrease stomach upset. The client should continue taking lithium as prescribed unless severe vomiting develops, at which time the medication should be held and the provider notified due to the risk of dehydration and resulting toxicity.
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? "If you do my homework for me, I won't bother you for the rest of the day." "Mom is always upset." "It's not the children's fault. It's mine." "It's your fault that we're having problems as a family."
"If you do my homework for me, I won't bother you for the rest of the day." This is an example of manipulative behavior. It is an example of manipulation when the family member uses a behavior to get what they desire rather than directly asking for what they want. "Mom is always upset." This is an example of generalizing. Instead of dealing with areas of conflict, family members use terms like "always" and "never" to avoid addressing specific problems. "It's not the children's fault. It's mine." This is an example of placating behavior, where one member of the family takes the blame to prevent an argument. "It's your fault that we're having problems as a family." This is an example of blaming behavior, where a family member blames others rather than taking responsibility for any failure.
A charge nurse is preparing an education session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? "Information regarding clients should remain confidential until after their death." "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." "As long as client identity is disguised, their health information can be shared between professionals on the internet." "In the event a client threatens harm to others, medications can be administered without consent."
"In the event a client threatens harm to others, medications can be administered without consent." The charge nurse should inform the participants that their primary commitment is to the client and their priority is always to advocate for and protect their health and safety. During an emergency situation, if the client is threatening harm to self or others, medications can be administered without the client's consent and without a court order. "Information regarding clients should remain confidential until after their death." The reputation of a client can still be tarnished after death; therefore, the charge nurse should inform the participants that any information which was kept confidential before a client's death should remain confidential after. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." Because laws vary from state to state, nurses should become familiar with the requirements as it relates to reporting neglect or maltreatment of clients. The nurse should inform the participants that in most states failure to report the suspected neglect, physical maltreatment, or exploitation of a disabled adult results in a misdemeanor charge. "As long as client identity is disguised, their health information can be shared between professionals on the internet." Information shared over the internet is not confidential and can be open to legal subpoenas; therefore, clients can be identified and initiate lawsuits against the individual who shared the information. The charge nurse should inform the participants to avoid sharing any client information on the internet.
A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? "I'm relieved now that my financial affairs are in order." "It is easier to talk about my feelings now." "Suddenly I have enough energy to do anything I want." "Thank you for always taking such good care of me."
"It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome. "I'm relieved now that my financial affairs are in order." When clients who have depression verbalize getting their affairs in order, they are at an increased risk for suicide. "Suddenly I have enough energy to do anything I want." When clients who have depression suddenly have more energy, they are at an increased risk for suicide. "Thank you for always taking such good care of me." Clients who have depression often show an appreciation for loved ones when they are contemplating suicide.
A nurse is caring for client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? "It will be better for you to keep busy to avoid thinking about your child's death." "You will complete the grieving process about a year after your child's death." "The grief process will start once your child actually dies." "It is not uncommon to feel angry toward yourself or others."
"It is not uncommon to feel angry toward yourself or others." Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss. "It will be better for you to keep busy to avoid thinking about your child's death." Encouraging the client to avoid thinking about the child's death will not allow the client to begin anticipatory grieving. "You will complete the grieving process about a year after your child's death." The grief process has no timeline. It varies for each individual. "The grief process will start once your child actually dies." The client can begin anticipatory grieving during the child's illness.
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? "Succinylcholine will enhance the therapeutic effects of this treatment." "Succinylcholine is given to reduce muscle movements during therapy." "Succinylcholine will decrease the anxiety level that you might experience with this treatment." "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure."
"Succinylcholine is given to reduce muscle movements during therapy." Succinylcholine is a muscle-paralyzing agent that will decrease muscle movement during the procedure so the client is less likely to be injured. "Succinylcholine will enhance the therapeutic effects of this treatment." The purpose of succinylcholine is not to increase the therapeutic effects of ECT. "Succinylcholine will decrease the anxiety level that you might experience with this treatment." Succinylcholine is not an antianxiety agent. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure." Succinylcholine is not a general anesthetic.
A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? "You might notice an increase in saliva while taking this medication." "You might experience difficulties with sexual functioning while taking this medication." "You should expect an improvement in symptoms of depression in 3 to 4 days." "You may notice a temporary ringing in the ears when starting this medication."
"You might experience difficulties with sexual functioning while taking this medication." Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs. "You might notice an increase in saliva while taking this medication." Fluoxetine does not cause an increase in saliva production. The nurse should instruct the client that they might experience dry mouth while taking fluoxetine. "You should expect an improvement in symptoms of depression in 3 to 4 days." The nurse should instruct the client that improvement in mood takes 1 to 3 weeks or longer following the initiation of therapy with fluoxetine. "You may notice a temporary ringing in the ears when starting this medication." Fluoxetine does not cause tinnitus. The nurse should instruct the client that they might experience visual disturbances, but the medication does not affect the ears.
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weights 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
14 mL
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? A client refuses electroconvulsive therapy after signing the consent form. A client who was voluntarily admitted left the unit against medical advice. A client was administered one-half of the prescribed dose of medication. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.
A client was administered one-half of the prescribed dose of medication. An incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form. A client refuses electroconvulsive therapy after signing the consent form. Self-determination is a client right that allows the client to change their mind and refuse treatment, even if a consent form had been signed previously. The nurse should document the client's refusal of treatment and notify the provider; however, completing an incident report is not necessary. A client who was voluntarily admitted left the unit against medical advice. Clients have the right to leave a mental health unit if they are voluntarily admitted. Restraining or preventing the client from leaving could constitute false imprisonment. The nurse should inform the provider, who might determine reevaluation of the client is necessary and ask the client to sign an "Against Medical Advice" form. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed. Restraints are used to maintain the safety of the client and others. If attempts to de-escalate behaviors are unsuccessful and restraints are necessary, the nurse should inform the provider to obtain a prescription for the restraints.
A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for flings indicating lithium toxicity? A client who has a fasting blood glucose level of 80 mg/dL A client who has a sodium level of 128 mEq/L A client who has a BUN of 18 mg/dL A client who has a potassium level of 3.6 mEq/L
A client who has a sodium level of 128 mEq/L A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level. A client who has a fasting blood glucose level of 80 mg/dL A fasting blood glucose level of 80 mg/dL is within the expected reference range and does not put the client at risk for lithium toxicity. A client who has a BUN of 18 mg/dLA BUN of 18 mg/dL is within the expected reference range and does not put the client at risk for lithium toxicity. A client who has a potassium level of 3.6 mEq/LA potassium level of 3.6 mEq/L is within the expected reference range and does not put the client at risk for lithium toxicity.
A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. A client who has borderline personality disorder threatened to harm their roommate. An adolescent client who has anorexia nervosa has a BMI of 17.
A client who has borderline personality disorder threatened to harm their roommate. Manifestations of borderline personality disorder include disturbed interpersonal relationships accompanied by threats and other-directed violence. While it is important for the nurse to maintain the client's confidentiality, on occasions when another individual's life might be in danger, the nurse is required by law to report it to authorities. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. The nurse has the duty to maintain confidentiality regarding the client's conversations with the nurse. Since genital herpes simplex virus is not a condition that needs to be reported, the nurse is not obligated to report the infection. The nurse should encourage the client to contact the client's sexual partners to inform them of the need to obtain testing and treatment if necessary. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. Anhedonia and loss of interest in the one's life are manifestations of depression. While a child who is in danger of abuse or neglect is reportable, a lack of interest in assisting with the care of children does not need to be reported. An adolescent client who has anorexia nervosa has a BMI of 17. A BMI of 17 is an indication of mild anorexia and, while this information is a part of the client's medical record, it does not need to be reported.
A nurse is caring for a group of clients. Which of the following findings should the nurse report? A client who is taking clozapine and has a WBC count of 7,500/mm3 A client who is taking lamotrigine and has developed a rash A client who is taking valproate and has a platelet count of 150,000/mm3 A client who is taking lithium and has a lithium level of 1.2 mEq/L
A client who is taking lamotrigine and has developed a rash Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately. A client who is taking clozapine and has a WBC count of 7,500/mm3 Clozapine can result in agranulocytosis, a potentially fatal disorder that increases the client's risk for infection. However, a WBC count of 7,500/mm3 is within the expected reference range. A client who is taking valproate and has a platelet count of 150,000/mm3 Valproate is a medication used in the treatment of bipolar disorder. The nurse should identify that decreased platelets is an adverse effect of the medication. However, a platelet count of 150,000/mm3 is within the expected reference range. A client who is taking lithium and has a lithium level of 1.2 mEq/L Lithium is a medication used for mood stabilization for clients who have bipolar disorder. The nurse should identify that the lithium toxicity can result in serious complications, including death. However, a lithium level of 1.2 mEq/L is within the therapeutic range.
A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? Feelings of remorse Extended periods of depression Deficits in intellectual functioning Aggression toward animals
Aggression toward animals The nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder. Feelings of remorse The nurse should identify that lack of remorse is an expected characteristic of a child who has conduct disorder. Extended periods of depression The nurse should identify that a child who has bipolar disorder is likely to have extended periods of depression. This is not an expected characteristic of a child who has conduct disorder. Deficits in intellectual functioning The nurse should identify that a child who has intellectual deficit disorder exhibits deficits in intellectual functioning, such as reasoning, abstract thinking, and academic ability. A deficit in intellectual functioning is not an expected characteristic of a child who has conduct disorder.
A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? Allow the client time to formulate an answer. Prompt the client to give a response. Move on to the next client. Offer the client a suggestion for a goal.
Allow the client time to formulate an answer. Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question. Prompt the client to give a response. A client who has depression might have a slow response rate. Prompting can place pressure on the client. Move on to the next client. Skipping the client might minimize the client's involvement in the group process and cause additional difficulty when answering the question. Offer the client a suggestion for a goal. A client who has depression is able to make decisions as necessary. Therefore, the nurse should not deny the client this ability to participate in the group therapy.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? Delusions Neologisms Anhedonia Echopraxia
Anhedonia Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking. Delusions Positive symptoms of schizophrenia usually appear suddenly and are alterations in behavior, perception, speech, and thought. Delusions and an inability to think abstractly are examples of positive symptoms. Neologisms Positive symptoms of schizophrenia usually appear suddenly and are alterations in behavior, perception, speech, and thought. Neologisms (made-up words) and echolalia (repeating someone else's words) are examples of positive symptoms. Echopraxia Positive symptoms of schizophrenia usually appear suddenly and are alterations in behavior, perception, speech, and thought. Motor agitation (a rapid increase in movement) and echopraxia (mimicking someone else's movements) are examples of positive symptoms.
A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? Arrange one-to-one observation of the client. Encourage interaction with the client's peers. Administer medication for depressive disorder. Encourage the client to attend a support group.
Arrange one-to-one observation of the client. The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety. Encourage interaction with the client's peers. Encouraging the client to interact with peers is important to facilitate socialization. However, another intervention is the priority. Administer medication for depressive disorder. Administering medication for depressive disorder is important to increase the client's mood over time. However, another intervention is the priority. Encourage the client to attend a support group. Encouraging the client to attend a support group is important. However, another intervention is the priority.
A nurse on a mental health unit is admitting a client who is anxious and tells the nurse,. "I hear voices telling me what to do." Which of the following actions should the nurse take? Tell the client that the voices do not really exist. Touch the client to help reduce feelings of anxiety. Instruct the client to go to a quiet room when the voices start talking. Ask the client what the voices are saying.
Ask the client what the voices are saying. It is important for the nurse to ask the client directly about the hallucinations to determine if the client or others are at risk for injury. Tell the client that the voices do not really exist. The nurse should avoid negating the client's hallucination. Touch the client to help reduce feelings of anxiety. The nurse should avoid touching the client without first asking for the client's permission. Touching the client violates one's personal space and can increase, rather than decrease, feelings of anxiety. Instruct the client to go to a quiet room when the voices start talking. The nurse should instruct the client to listen to music or use other auditory distractions when the voices are talking.
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? Call the family member to the side to inquire if they have questions or concerns about the treatment plan. Advise the family member that this treatment plan has been developed specifically for the client to follow. Ask the family member if they have any thoughts or questions about the treatment plan. Document that the family member does not support the medication treatment plan.
Ask the family member if they have any thoughts or questions about the treatment plan. This action involves the family member and allows them a venue to communicate about the client's medication treatment plan. Call the family member to the side to inquire if they have questions or concerns about the treatment plan. This action might exacerbate the client's paranoia. Calling the family member aside can lead the client to assume that the nurse is sharing undisclosed information with the family member and not with the client. Advise the family member that this treatment plan has been developed specifically for the client to follow. This action dismisses the family member's concern and does not encourage participation in treatment planning. Document that the family member does not support the medication treatment plan. This action demonstrates that the nurse is making an assumption.
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should there nurse take? Ask the client to identify the bomb in the room. Initiate disaster protocols per facility policies and procedures. Assess the client for evidence of a perceptual disturbance. Convince the client that there is no bomb in their room.
Assess the client for evidence of a perceptual disturbance. The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions. Ask the client to identify the bomb in the room. Asking the client to identify the bomb in the room is an inappropriate action because the nurse is responding as if the hallucination is real. Initiate disaster protocols per facility policies and procedures. Without evidence of a disaster on a mental health unit, it is inappropriate to initiate disaster protocols. Convince the client that there is no bomb in their room. Trying to convince the client that there is not a bomb in their room negates the client's experience.
A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include? Taking the oral medication buprenorphine to prevent alcohol use Attending a relapse prevention group several times each week Beginning a methadone treatment program at a local center Living with their parent, who has promised to keep them away from alcohol
Attending a relapse prevention group several times each week The nurse should identify that the most effective strategy for relapse prevention is a 12-step program, such as Alcoholics Anonymous. Taking the oral medication buprenorphine to prevent alcohol use The nurse should identify that buprenorphine is used to treat opioid use disorder, not alcohol use disorder. Beginning a methadone treatment program at a local center The nurse should identify that methadone is used to treat opioid use disorder, not alcohol use disorder. Living with their parent, who has promised to keep them away from alcohol The nurse should identify that the client should take responsibility for their own actions, not assign the responsibility to another family member.
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? Offering self Use of silence Attention to body language Reflection of feelings
Attention to body language Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language. Offering self The nurse uses this therapeutic technique to demonstrate genuine interest in the client. Use of silence The nurse uses this therapeutic technique to demonstrate willingness to wait for the client's response. Reflection of feelings The nurse uses this therapeutic technique to encourage the client to acknowledge their feelings.
A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? Ensure a family member can be present during treatment. Increase fluid intake for 24 hr before the treatment starts. Change position slowly when the treatment is complete. Avoid looking directly at the light during treatment.
Avoid looking directly at the light during treatment. Light therapy, or phototherapy, can cause sensitivity to light. To minimize this effect, the client should avoid looking directly at the light. Ensure a family member can be present during treatment. This precaution is not necessary for light therapy. Increase fluid intake for 24 hr before the treatment starts. Light therapy does not increase the risk of dehydration. Change position slowly when the treatment is complete. Light therapy is unlikely to cause orthostatic hypotension or dizziness
A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? Obtain the weight of a client who has bipolar disorder and is experiencing mania. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.
Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound. Obtain the weight of a client who has bipolar disorder and is experiencing mania. A client who has bipolar disorder and is experiencing mania can exhibit weight loss caused by decreased caloric intake and hyperactivity. Obtaining the weight of a client is within the range of function of the assistive personnel. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. A client who has anorexia nervosa severely restricts nutritional intake over a fear of gaining weight. Even if the client does eat, they are at risk for purging following the meal. It is important to stay with the client throughout the meal and observe them for at least 1 hr after eating to ensure the meal is eaten and not purged. Assessing the nutritional intake of a client who has anorexia nervosa is within the scope of practice for an RN. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. Serotonin syndrome is a life-threatening adverse reaction associated with selective serotonin reuptake inhibitors. A client who is experiencing serotonin syndrome is unstable; therefore, the registered nurse should provide care and monitoring to this client.
A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? Clang association Word salad Neologism Echolalia
Clang association The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have a similar sound. Word salad In word salad, words are completely meaningless and disorganized. This client's speech pattern is not word salad. Neologism Neologism consists of words that are made up by the client. This client's speech pattern does not contain neologisms. Echolalia In echolalia, the client repeats the words of another person. This client's speech pattern is not echolalia.
A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomexetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? Reduced appetite Fatigue Dark urine Sweating
Dark urine The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death. Therefore, this is the nurse's priority finding. Reduced appetite Although reduced appetite is an adverse effect of this medication and the child should be weighed regularly to monitor this adverse effect, another finding is the nurse's priority. Fatigue Although fatigue is an adverse effect of this medication, another finding is the nurse's priority. Sweating Although sweating is an adverse effect of this medication, another finding is the nurse's priority.
A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first? Administer phentolamine 5 mg IV to the client. Apply a hypothermic blanket to the client. Determine the client's prescribed medication regimen. Initiate IV access for the client.
Determine the client's prescribed medication regimen. The first action the nurse should take when using the nursing process is to assess the client. By determining the client's prescribed medications, the nurse can determine the cause of the hypertension, such as the client taking an MAOI to treat depression. These medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine. Administer phentolamine 5 mg IV to the client. The nurse should administer phentolamine 5 mg IV to lower the client's blood pressure. However, there is another action the nurse should take first. Apply a hypothermic blanket to the client. The nurse should apply a hypothermic blanket to the client to decrease pyrexia. However, there is another action the nurse should take first. Initiate IV access for the client. The nurse should initiate IV access because fluid therapy is essential to decrease hyperthermia. However, there is another action the nurse should take first.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?
Diazepam 5 mg IV bolus The greatest risk to the client who is experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations. Clonidine 0.1 mg transdermal patch Clonidine can stabilize vital signs and is used as an adjunct to a benzodiazepine. It is administered PO or transdermal for treatment of hypertension and does not act rapidly. Therefore, it is not the first medication the nurse should administer. Naltrexone 380 mg IM Naltrexone can be given to assist with long-term abstinence maintenance. However, it is not the first medication the nurse should administer. Bupropion 150 mg PO Bupropion can be given for smoking cessation. However, it is not the first medication the nurse should administer.
A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? Do not administer the lorazepam. Request a prescription for IV lorazepam. Request that another nurse attempt to administer the lorazepam. Place the lorazepam in the client's food.
Do not administer the lorazepam. Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment. Therefore, the nurse should hold the medication and document the client's refusal. Request a prescription for IV lorazepam.Requesting a prescription for and administering IV lorazepam violates the client's right to refuse treatment. Request that another nurse attempt to administer the lorazepam.Requesting that another nurse attempt to administer the lorazepam violates the client's right to refuse treatment. Place the lorazepam in the client's food.Placing the lorazepam in the client's food violates the client's right to refuse treatment.
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? Emotional lability Self-sacrificing Suspicious of others Grandiosity
Emotional lability Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances. Self-sacrificing Being self-sacrificing is a feature of dependent personality disorder. These clients are also excessively clingy and submissive. Suspicious of others Being suspicious of others is a feature of paranoid personality disorder. These clients also project blame onto others and can be hostile and violent. Grandiosity Feelings of grandiosity are a feature of narcissistic personality disorder. These clients are also exploitive, filled with rage, and are sensitive to criticism.
A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? Have the client participate in a morning aerobics group. Encourage frequent rest periods throughout the day. Provide a distraction such as television at night. Offer the client hot chocolate at bedtime.
Encourage frequent rest periods throughout the day. A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion. Have the client participate in a morning aerobics group. The nurse should direct the client to areas with minimal activity to decrease stimulation. Provide a distraction such as television at night. A client who is experiencing mania requires a reduction in environmental stimuli to avoid continued agitation and tension. The nurse should provide the client with a quiet and low-stimulation environment to decrease excitability. Offer the client hot chocolate at bedtime. The nurse should integrate interventions to promote sleep, such as soft music, a quiet room, or warm milk. However, chocolate contains caffeine, a stimulant, which can hinder rest.
A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? Encourage the client to drink 125 mL of fluid each hour while awake. Allow the client to eat independently in their room. Weigh the client twice weekly. Measure the client's vital signs once each day.
Encourage the client to drink 125 mL of fluid each hour while awake. The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration. Allow the client to eat independently in their room. The nurse should remain with the client during the duration of meals to prevent the client from purging or hiding food in clothing. Weigh the client twice weekly. For the first week of treatment, the nurse should weigh the client daily upon waking, after voiding, and before having anything to drink or eat. Thereafter, the nurse should weigh the client three times per week. Measure the client's vital signs once each day. Initially, the nurse should measure the client's vital signs three times each day until the client's weight increases and cardiovascular status improves.
A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) Feelings of hopelessness Pressured speech Grandiosity Anhedonia Flat facial expression
Feelings of hopelessness Anhedonia Flat facial expression -- Feelings of hopelessness is correct. The nurse should document feelings of hopelessness as a clinical manifestation of major depressive disorder. Pressured speech is incorrect. This clinical manifestation is associated with clients who are experiencing mania, rather than major depressive disorder. Grandiosity is incorrect. This clinical manifestation is associated with clients who are experiencing mania, rather than major depressive disorder. Anhedonia is correct. The nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorder. Flat facial expression is correct. The nurse should document a flat facial expression as a clinical manifestation of major depressive disorder.
A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestation. The nurse should teach the partner to expect which of the following manifestations to occur first? Inability to recognize family members Chooses clothing that is inappropriate for the weather Exhibits a change in personality Frequently misplaces objects
Frequently misplaces objects According to evidence-based practice, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur. Inability to recognize family members The inability to recognize family members manifests as Alzheimer's disease progresses. However, evidence-based practice indicates that another manifestation is expected to occur first. Chooses clothing that is inappropriate for the weather Difficulty choosing clothing that is appropriate for the weather manifests as Alzheimer's disease progresses. However, evidence-based practice indicates that another manifestation is expected to occur first. Exhibits a change in personality A change in personality manifests as Alzheimer's disease progresses. However, evidence-based practice indicates that another manifestation is expected to occur first.
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take? Gather supplies for endotracheal intubation. Administer a beta blocker intravenously. Position the client in a low-Fowler's position. Place a cooling blanket over the client.
Gather supplies for endotracheal intubation The nurse should gather supplies for endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression. Administer a beta blocker intravenously. Hypotension is an expected finding in a client who has alcohol toxicity. Therefore, it is not an appropriate nursing action to administer medications that will lower the client's blood pressure. Position the client in a low-Fowler's position. Aspiration of emesis is a potential risk for a client. The nurse should implement measures to reduce the risk of aspiration of emesis for a client who has alcohol poisoning. Low-Fowler's position can increase the client's risk for aspiration. Place a cooling blanket over the client. The nurse should expect the client who has alcohol toxicity to have cool skin. Therefore, the nurse should place a warming blanket over the client.
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? Sore throat Photophobia Hand tremors Constipation
Hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication. Sore throat A sore throat is not an expected adverse effect of lithium. Photophobia Photophobia is not an expected adverse effect of lithium. Constipation Diarrhea is an early manifestation of lithium toxicity.
A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? Polyphagia Hypertension Decreased temperature Depressed mood
Hypertension Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism. Polyphagia Cocaine is a stimulant that decreases appetite. Decreased temperature Cocaine is a stimulant that increases body temperature. Depressed mood Cocaine is a stimulant that causes feelings of exhilaration and increased energy.
A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? Increased confusion Sleep disturbances Cluttered environment Inappropriate dress
Inappropriate dress Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect. Increased confusion Increased confusion is an indicator of psychological abuse. Sleep disturbances Sleep disturbances are an indicator of psychological abuse. Cluttered environment A cluttered environment is not an indicator of neglect.
A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? Advise the client to take frequent sips of water. Instruct the client to avoid driving during initial therapy. Consult a dietitian for a calorie-controlled diet plan. Recommend that the client exercise regularly.
Instruct the client to avoid driving during initial therapy. The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy. Advise the client to take frequent sips of water. The nurse should advise the client to take frequent sips of water due to the adverse effect of dry mouth. However, this is not the nurse's priority intervention. Consult a dietitian for a calorie-controlled diet plan.The nurse should consult a dietitian for a calorie-controlled diet plan due to the adverse effect of weight gain. However, this is not the nurse's priority intervention. Recommend that the client exercise regularly.The nurse should advise the client to exercise regularly due to the adverse effects of weight gain and constipation. However, this is not the nurse's priority intervention.
A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? Raise the pitch of the voice when speaking to the client. Begin the interview by explaining the plan of care. Interview the client in a private setting. Ask the client to complete a detailed questionnaire.
Interview the client in a private setting. The nurse should interview clients in a private place when asking questions regarding client health. Raise the pitch of the voice when speaking to the client. The nurse should use a lower pitch of voice when speaking because older adult clients are typically able to hear words that are spoken with a lower pitch. Begin the interview by explaining the plan of care. The nurse should begin the interview by asking the client to identify their needs and concerns. This data is then used to create a personalized plan of care. Ask the client to complete a detailed questionnaire. The nurse should limit the number of items on a questionnaire when gathering data from an older adult client.
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? Diarrhea Heavy menstrual bleeding Tachycardia Orthostatic hypotension
Orthostatic hypotension Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension. Diarrhea Constipation is a manifestation of anorexia nervosa. Decreased food and fluid intake cause constipation. Heavy menstrual bleeding Amenorrhea is a manifestation of anorexia nervosa. Low weight, decreased body fat, and poor nutrition cause amenorrhea. Tachycardia Bradycardia is a manifestation of anorexia nervosa. Starvation and dehydration cause cardiovascular abnormalities, including bradycardia.
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? Promote the use of music to compete with the client's auditory hallucinations. Inform the client that the auditory hallucinations are not real. Avoid asking the client if they are experiencing auditory hallucinations. Instruct the client on the use of voice recognition regarding the auditory hallucinations.
Promote the use of music to compete with the client's auditory hallucinations. Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level. Inform the client that the auditory hallucinations are not real. Informing a client that auditory hallucinations are not real will increase the client's anxiety level. The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that they do not hear anything to reinforce reality. Avoid asking the client if they are experiencing auditory hallucinations. The nurse should ask the client if they are hearing voices to evaluate whether these are command hallucinations, which can place the client or others at risk for harm. Instruct the client on the use of voice recognition regarding the auditory hallucinations. The nurse should assist the client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to stop, which gives the client a sense of control.
A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse? Schedule the client for group therapy sessions. Maintain consistent rules. Provide frequent high-calorie snacks. Avoid the use of value judgments.
Provide frequent high-calorie snacks. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take. Schedule the client for group therapy sessions. The nurse should incorporate group therapy in the client's care. However, this is not the priority action for the nurse to take. Maintain consistent rules. The nurse should maintain consistent rules to minimize the client's manipulation of the staff. However, this is not the priority action for the nurse to take. Avoid the use of value judgments. The nurse should avoid value judgments to minimize escalating mania. However, this is not the priority action for the nurse to take.
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? Controls anger outbursts to avoid being placed in seclusion No longer exhibits a fear of social or public situations Refrains from manipulating others to earn dining room privileges Imitates the therapist's use of a relaxation technique
Refrains from manipulating others to earn dining room privileges The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response. Controls anger outbursts to avoid being placed in seclusion Changing behavior to avoid punishment is not an optimal goal of operant conditioning therapy. No longer exhibits a fear of social or public situations There is no evidence that this client has a social phobia. Phobias are usually treated with desensitization therapy. Imitates the therapist's use of a relaxation technique Imitating behavior is modeling and does not demonstrate the desired outcome of operant conditioning.
A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? Decrease distractions during meal times. Provide positive feedback when the child completes a task. Clearly identify consequences for unacceptable behavior. Remove unnecessary equipment from the child's surroundings.
Remove unnecessary equipment from the child's surroundings. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings. Decrease distractions during meal times. The nurse should decrease distractions during meal times for a child who has ADHD. However, this intervention does not address the greatest risk to the child and therefore, is not the priority intervention. Provide positive feedback when the child completes a task. The nurse should provide positive feedback for task completion for a child who has ADHD. However, this intervention does not address the greatest risk to the child and therefore, is not the priority intervention. Clearly identify consequences for unacceptable behavior. The nurse should clearly identify consequences for unacceptable behavior for a child who has ADHD. However, this intervention does not address the greatest risk to the child and therefore, is not the priority intervention.
A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? Confront the staff member. Encourage the client to report the incident. Document the incident in the client's health record. Report the occurrence to the charge nurse.
Report the occurrence to the charge nurse. It is the charge nurse and the nurse manager's responsibility to confront the staff member about the derogatory comments made to the client. Confront the staff member. It is not the responsibility of the nurse to discipline other staff members. Encourage the client to report the incident. This action takes the responsibility away from the nurse who has overheard the comments. Document the incident in the client's health record. The incident should not be documented in the client's health record.
A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? Respite care Partial hospitalization Adult day care program Geropsychiatric unit
Respite care Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves. Partial hospitalization Partial hospitalization provides services for several hours during the day, but they are not designed to offer 24-hr care. A client who has advanced Alzheimer's disease is unable to safely remain at home unattended. Adult day care program Adult day care programs provide services throughout the day to clients who have Alzheimer's disease, allowing the caregiver the ability to work or have a break. The clients return home in the evening. A client who has advanced Alzheimer's disease is unable to safely remain at home unattended. Geropsychiatric unit A geropsychiatric unit provides care for clients requiring acute psychiatric services due to sudden mental status changes, psychosis, or other mental health issues. These services are ideal for clients who are at risk of harming themselves or others.
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? Behave in a friendly manner toward the client. Set realistic limits on the client's behavior. Show respect for the client's need for isolation. Act as a role model for assertiveness.
Set realistic limits on the client's behavior. Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish clear limits on specific aggressive and demanding behaviors. Behave in a friendly manner toward the client. Clients who have antisocial personality disorder might perceive friendliness as an invitation for manipulative and seductive behavior. This strategy should be used for clients who have avoidant personality disorder. Show respect for the client's need for isolation. Clients who have antisocial personality disorder do not seek isolation. They show antagonistic behavior toward others and often have a history of criminal misconduct. This strategy should be used for clients who have schizotypal personality disorder. Act as a role model for assertiveness. Clients who have antisocial personality disorder do not lack assertiveness. They tend to act in an aggressive and exploitative manner. This strategy should be used for clients who have dependent or histrionic personality disorders.
A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? Shuffling gait Hypotension Decreased WBC count Blurred vision
Shuffling gait Benztropine is used to treat parkinsonism manifestations, such as shuffling gait. Hypotension Orthostatic hypotension is an adverse effect of conventional antipsychotic medications. However, it is not treated with benztropine. Decreased WBC count Agranulocytosis is an adverse effect of conventional antipsychotic medications. However, it is not treated with benztropine. Blurred vision Blurred vision is an adverse anticholinergic effect of conventional antipsychotic medications. However, it is not treated with benztropine.
A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? St. John's wort Saw palmetto Echinacea Ginkgo
St. John's wort St. John's wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome. Saw palmetto Saw palmetto is used to treat benign prostatic hyperplasia. It does not interact adversely with paroxetine. Echinacea Echinacea is used to enhance immune function. It does not interact adversely with paroxetine. Ginkgo Ginkgo is used to relieve pain from peripheral arterial disease. It does not interact adversely with paroxetine.
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? Male gender Hyperthyroidism Substance use disorder Being married
Substance use disorder The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders. Male gender The nurse should identify that female clients are at an increased risk for the development of depressive disorders. Hyperthyroidism The nurse should identify that clients who have hypothyroidism are at an increased risk for the development of depressive disorders. Being married The nurse should identify that clients who are single are at an increased risk for the development of depressive disorders.
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? Move the client to a room near the nurses' station. Limit visitors until the client is oriented to the environment. Tell the client that their partner is deceased. Talk with the client about activities they enjoyed with their partner.
Talk with the client about activities they enjoyed with their partner. Talking about positive experiences can help distract the client from their disorientation. Move the client to a room near the nurses' station. When caring for a client who has dementia, avoid placing the client in unfamiliar settings whenever possible. Limit visitors until the client is oriented to the environment. Family members should be encouraged to interact with the client regardless of the client's state of dementia. Tell the client that their partner is deceased. Confrontation should not be used for a client who is disoriented.
During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? The client is interested in what the nurse is saying. The client is attempting to manipulate the nurse. The client is physically attracted to the nurse. The client needs to feel accepted by the nurse.
The client is interested in what the nurse is saying. The client's posture and eye contact demonstrates an interest in the interview and what the nurse is saying. The client is attempting to manipulate the nurse. This client's nonverbal behavior shows no evidence of manipulation. The client is physically attracted to the nurse. This client's nonverbal behavior shows no evidence of physical attraction to the nurse. The client needs to feel accepted by the nurse. The client is demonstrating a level of interest and awareness. There is no indication at this point of the client's need for acceptance.
While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? The client needs excessive external input to make everyday decisions. The client demonstrates a dedication to their job that excludes time for leisure activities. The client adheres to a rigid set of rules. The client has difficulty starting new relationships unless they feel accepted.
The client needs excessive external input to make everyday decisions. Clients who have dependent personality disorder need excessive input from others to make everyday decisions. The client demonstrates a dedication to their job that excludes time for leisure activities. Clients who have obsessive-compulsive personality disorder demonstrate a dedication to work that excludes time for other activities. The client adheres to a rigid set of rules. Clients who have obsessive-compulsive personality disorder adhere to a rigid set of rules. The client has difficulty starting new relationships unless they feel accepted. Clients who have avoidant personality disorder are unwilling to get involved socially unless they feel accepted.
A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? The client recently lost a grandparent in a motor vehicle crash. The client's town was hit by a tornado. The client's youngest child is leaving for college. The client is ambivalent about their upcoming retirement.
The client recently lost a grandparent in a motor vehicle crash. The client experiences a situational crisis when an unexpected event occurs. The client's town was hit by a tornado. The client experiences an adventitious crisis when an external disaster occurs. The client's youngest child is leaving for college. The client experiences a maturational crisis during a natural life event. The client is ambivalent about their upcoming retirement. The client experiences a maturational crisis during a natural life event.
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. The client reports an inability to breathe easily. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. The client reports having recently started smoking cigarettes.
The client reports an inability to breathe easily. Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. Weight gain is an adverse effect of clozapine that can also lead to hyperlipidemia and hyperglycemia. The nurse should notify the provider so additional laboratory tests and nutritional counseling can be prescribed; however, this is not the priority finding for the nurse to report to the provider. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL.Hyperglycemia is an adverse effect associated with clozapine. The nurse should notify the provider so additional laboratory tests and nutrition counseling can be prescribed; however, it is not the priority finding for the nurse to report to the provider. The client reports having recently started smoking cigarettes.Nicotine decreases the concentration of clozapine in the system. The nurse should identify that the client might require dosage adjustment and report this finding to the provider; however, it is not the priority finding to report to the provider.
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? The client is exhibiting echolalia. The client reports command hallucinations. The client reports loss of motivation. The client is exhibiting blunted affect.
The client reports command hallucinations. The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others. The client is exhibiting echolalia. The nurse should identify that echolalia, or the repeating of another's words, is an expected manifestation of schizophrenia. The client reports loss of motivation.The nurse should identify that a loss of motivation, or avolition, is an expected manifestation of schizophrenia. The client is exhibiting blunted affect.The nurse should identify that blunted affect, or a decreased emotional response, is an expected manifestation of schizophrenia.
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? The client will take prescribed medications as scheduled. The client will express feelings of frustration. The client will refrain from self-mutilation. The client will participate in group therapy.
The client will refrain from self-mutilation. The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the client to refrain from self-mutilation. The client will take prescribed medications as scheduled. Taking prescribed medications as scheduled to maintain therapeutic blood levels is an important goal. However, this is not the priority goal. The client will express feelings of frustration. Expressing feelings of frustration to acknowledge these feelings is an important goal. However, this is not the priority goal. The client will participate in group therapy. Participating in group therapy as part of the treatment plan is an important goal. However, this is not the priority goal.
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? Total body fat 8.7% Potassium 3.6 mEq/L Temperature 36.1° C (96.9° F) Heart rate 54/min
Total body fat 8.7% The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider. Potassium 3.6 mEq/L Electrolyte levels significantly above or below the expected reference range are criteria for hospitalization. A client who has anorexia nervosa can experience hypokalemia; however, a potassium level of 3.6 mEq/L is within the expected reference range. Temperature 36.1° C (96.9° F) Criteria for hospitalization include a temperature less than 36° C (96.8° F). Heart rate 54/min Criteria for hospitalization is a heart rate less than 50/min during the daytime.