ATI Missed

A nurse in the emergency department is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and discharges the client. Which of the following actions should the nurse take? A. Request a social services consultation B. Contact the child's guardian to discuss the suspicion C. Report the provider's actions to the state medical board D. Report the suspected abuse to law enforcement

Correct Answer: D. Nurses are legally mandated to report suspected child and vulnerable adult abuse. The nurse should report the suspected child abuse to the appropriate agency of the state in which she is practicing. Incorrect Answers: A. HIPAA regulations do not supersede the suspicion of abuse. B. C. The nurse should report the suspected abuse to the appropriate state agency.

A nurse is assessing the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills

Correct Answer: D. The nurse should assess the lethality of a client's suicide plan and identify the method as hard or soft. Ingesting antidepressants or other pills is considered a soft method due to the lower risk of resulting in death. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun. Incorrect Answers: A. Jumping off a bridge or another high place is considered a hard method because it has a higher risk of resulting in death than soft methods. B. Inhaling carbon monoxide is considered a hard method. C. Hanging is considered a hard method.

A client who has hypertension tells the nurse in a provider's office that she feels the considerable amount of stress at work 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 then try to reduce them C. Plan for periods away from work throughout the day D. Improve her ability to cope with identified stressors

Correct Answer: D. The nurse should help the client learn stress-management techniques to deal with stress without internalizing it. Incorrect Answers: A. Changing jobs is not a long-term solution and is among the top 10 life stressors. Even if the new job seems less stressful at first, some stressors will likely emerge over time. B. If the client had control over work stressors, it is unlikely that she would report somatic effects of job stress. C. The client likely cannot take periods of time away from work that are frequent or long enough to relieve work-related stress.

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

Correct Answer: A. EBP indicates the nurse should 1st refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so inpatient hospitalizations can be avoided. Incorrect Answers: B. The nurse should refer the client to a support group; (nurse should make a different referral first) C. The nurse should refer the client to private counseling; (nurse should make a different referral first) D. The nurse should refer the client to vocational rehabilitation services; (nurse should make a different referral first)

A nurse is assessing a client prior to administering lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4 lb) since the start of treatment C. Fine hand tremors in both hands D. Serum lithium level of 1.1 mEq/L

Correct Answer: A. GI upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. You should assess the client for indications of dehydration, which further increases the risk of lithium toxicity. Incorrect Answers: B. You should expect a weight gain of up to 2.3 kg (5 lb) during the first week of treatment with lithium; therefore, the nurse should administer the dose as prescribed. C. You should expect a client who recently began taking lithium to have FINE hand tremors. This adverse effect usually diminishes with continued Tx; therefore, the nurse should administer the dose as prescribed. D. A serum lithium level of 1.1 mEq/L is within the expected reference range

A nurse in an acute care mental health facility observes a client who has bipolar disorder begin to shout and use offensive language toward a visitor. Which of the following actions should the nurse take? A. Give the client 2 options for ending the situation B. Move quickly to stand directly in front of the client before speaking C. Direct other clients to move toward the client as a show of force D. Tell the client that the conversation will be ended if the shouting continues

Correct Answer: A. Giving the client several options (e.g. 2 different locations in which to be away from visitors and other clients) PREVENTS the client from feeling POWERLESSNESS and gives the client some responsibility for making choices. Incorrect Answers: B. Moving quickly to stand directly in front of the client can be perceived as a threat by the client. You should approach the client from the side, stand out of the client's reach, and move in a controlled, calm way to avoid provoking increased anxiety and aggression. C. You should move other clients and visitors AWAY from the client for their safety. Staff should stay in the room for backup but should not appear to threaten the client. D. You should avoid ending the conversation with the client. It's important to speak calmly & quietly to the client, using open-ended statements to de-escalate the violent situation.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take? A. Administer oxygen B. Administer an anticonvulsant C. Administer an opioid antagonist D. Administer IV fluids

Correct Answer: A. In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require O2 administration until their respiratory status is stable. Incorrect Answers: B. Although ECT causes brief seizures that last <1 min during the procedure, clients are not typically at further risk for seizures following the procedure. C. The client will receive a muscle relaxant and an anesthetic agent in preparation for the procedure, NOT an opioid. D. Although the client will have received IV medication for the procedure, the nurse does NOT have to administer IV hydration after the procedure. Once the client recovers from the medications the procedure requires, oral intake can resume.

A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make? A. "Light therapy suppresses the natural nighttime release of melatonin." B. "You should plan your light therapy session before going to bed." C. "You should begin with 2-minute light therapy sessions and gradually progress to 10-minute sessions." D. "Light therapy is less effective at treating SAD than antidepressant medications."

Correct Answer: A. Melatonin (produced nocturnally by the pineal gland), larger amounts are produced during months containing more hours of darkness. These large amounts of melatonin seem to cause SAD in clients who are susceptible to this disorder. Light therapy is thought to improve depression by suppressing melatonin production and increasing serotonin production. Incorrect Answers: B. Exposure to light therapy before bedtime can cause insomnia. Tx shortly after waking is recommended. Some clients obtain good results at other times of the day or with divided treatment times. C. Client should begin light therapy with 10-15 minute sessions and gradually progress to sessions lasting 30-45 minutes. Increased doses can cause adverse effects (headaches, eyestrain, irritability). D. Inform client that light therapy is a primary treatment for SAD. Studies show that clients who have SAD and use light therapy note improvement of symptoms similar to the improvements clients experience with meds.

A nurse is caring for a client who has social anxiety disorder. Which of the following client statements should the nurse expect? A. "I am embarrassed to eat in public." B. "I often feel like I am going to have a heart attack." C. "I struggle to control my constant worry." D. "I have to step over the cracks in the sidewalk or else something bad might happen."

Correct Answer: A. Recognize that this statement describes social anxiety disorder. Clients who have this disorder experience severe anxiety or fear of behaving in a manner that can be negatively viewed by others. These clients attempt to avoid activities such as eating or speaking in public. If they are unable to avoid activities that trigger the anxiety, clients experience severe anxiety and emotional distress. Incorrect Answers: B. You should recognize that this statement describes a PANIC DISORDER, which manifests as a feeling of impending doom. Panic attacks are unpredictable and intense, and cause a variety of stress-related physical manifestations (attacks usually last a few minutes and then subside). C. You should recognize that this statement describes GAD, which manifests as excessive worry. Causes impaired concentration that can lead to fatigue, irritability, and sleep disturbances. D. You should recognize that this statement OCD, which manifests in the performance of repetitive behaviors. They adhere to stringent rules and routines that can occupy much of their time.

A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? A. "Yesterday, my partner put on a jacket upside down." B. "My partner has trouble reading the newspaper." C. "My partner often repeats words." D. "Last week, my partner did not recognize the sound of the alarm clock."

Correct Answer: A. Recognize that this statement is an indication that the client is experiencing APRAXIA (the lack of ability to accomplish once known tasks). This manifestation is considered a COGNITIVE deficit because there is no loss of motor or sensory ability. Incorrect : B. Recognize that this statement is an indication that the client is experiencing AGRAPHIA, which is the decreasing ability to READ or WRITE. This COGNITIVE decline occurs early in the disease. C. Recognize that this statement is an indication that the client is experiencing PRESERVATION, which is the repetition of a word or phrase. D. Recognize that this statement is an indication that the client is experiencing AGNOSIA, which is the loss of the ability to recognize objects. The loss can be AUDITORY, VISUAL, or TACTILE.

A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for this therapy? A. The client will gain increased self-esteem. B. The client will maintain orientation to place and time. C. The client will independently perform ADLs. D. The client will achieve optimal sensory stimulation.

Correct Answer: A. The nurse should use reminiscence therapy to assist the client in reflecting on past experiences. This review of the client's life is intended to increase the client's self-esteem and promote ego integrity. Incorrect Answers: B. The nurse should use reorientation strategies to assist the client in achieving and maintaining orientation. C. The nurse should promote independence in ADLs for a client who has a self-care deficit. D. The nurse should promote sensory stimulation for a client who has diminished sensory perception.

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect? A. "I pick my face when I am nervous." B. "I have bald patches from pulling out my hair." C. "I inspect my body in the mirror several times a day." D. "I am unable to part with any of my belongings."

Correct Answer: A. This statement is an indication of excoriation disorder. Clients who have excoriation disorder typically pick their faces when experiencing stress or anxiety. Incorrect Answers: B. This statement is an indication of trichotillomania (hair pulling disorder). Hair is typically pulled from the head, although other parts of the body with hair can be affected. For some clients, the pain experienced from pulling their hair reduces stress and anxiety. C. This statement is an indication of body dysmorphic disorder. Clients who have body dysmorphic disorder obsessively believe their body is defective in some manner. The preoccupation with these false beliefs can lead to depression and self-shame. Suicide risk is high for clients who have this disorder. D. This statement is an indication of hoarding disorder (manifests as inability to discard any belongings). Possessions can collect to the point of completely filling the client's place of residence, which can lead to an unsafe or unsanitary environment (disorder can stem from a stressful event and, eventually, can become so pervasive that it impairs normal living).

A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory? A. "In what year did you graduate from high school?" B. "What is your favorite childhood memory?" C. "What did you have for supper yesterday?" D. "What is today's date?"

Correct Answer: A. When assessing a client's remote memory, you should ask questions that determine the client's ability to remember things from the distant past. You should ask questions that can be validated to ensure the information is correct. Incorrect Answers: B. When assessing the client's memory, you should ask questions that can be validated. The client could use confabulation to develop an answer about childhood memories; therefore, this question does not accurately assess the client's remote memory. C. You should ask questions about the past few days when assessing the client's RECENT memory. D. You should ask the client about the current date when assessing the client's ORIENTATION.

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

Correct Answer: A. You should identify that all SGA medications (e.g., risperidone) can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. If there is no change after 12 weeks, glucose should be monitored annually. Incorrect Answers: B. Risperidone does not cause an elevated WBCs. Agranulocytosis can occur as an adverse effect of clozapine, another SGA. Leukopenia and neutropenia can occur as adverse effects of olanzapine and ziprasidone, which are other SGAs. C. Risperidone does not cause a decreased platelet count. D. Risperidone does not affect liver enzymes such as the AST level. Can cause dyslipidemia, which should be monitored at baseline and every 6 months thereafter.

A nurse is assessing 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

Correct Answer: A. Paranoia Acute effects of methamphetamine use include increased HR and metabolism, mental alertness, reduced appetite, and paranoia. Incorrect Answers: B. C. Clients who are under the influence of methamphetamine exhibit increased energy and mental alertness. Clients who are under the influence of alcohol exhibit slurred speech. D. Clients who are under the influence of methamphetamine exhibit increased HR and BP.

A mental health nurse is reviewing a process recording of a therapy session with a client. Which of the following statements should the nurse identify as an example of the communication technique of reflection? A. "I notice you are pulling on your hair when we discuss your dismissal." B. "That statement made by the other client appears to have upset you." C. "Since writing in your journal is frustrating, we should look at this activity more closely." D. "Give me an example of a time when you felt no one understood you."

Correct Answer: B Reflective statements are useful in assisting a client with identifying emotions and ideas. This therapeutic communication technique validates the client's emotions and encourages the client to reflect more deeply on the emotion. Incorrect Answers: A. To assist the client in noticing behaviors, the nurse can use the therapeutic technique of MAKING OBSERVATIONS (allows client to gain understanding between the emotions being felt and the topic of discussion or thoughts the client might be having). Promotes mutual understanding of perceptions between the client and the nurse. C. To delve more deeply into an important topic, you can use the therapeutic technique of FOCUSING. Useful when the client jumps from topic to topic. You should avoid using focusing during periods of client anxiety because this can increase the client's anxiety. D. To assist a client in explaining a vague concept such as "no one understands me," the nurse can use the therapeutic technique of SEEKING CLARIFICATION. This increases the nurse's understanding of the client's point of view, which can enhance the nurse-client relationship.

A nurse is teaching a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should inform the client that TMS can cause which of the following adverse effects? A. Retrograde amnesia B. Seizures C. Confusion D. Suicidal ideation

Correct Answer: B. Although uncommon, seizures are a potential adverse effect of TMS. Incorrect Answers: A. Retrograde amnesia is a potential adverse effect of ECT rather than TMS. C. Confusion is a potential adverse effect of ECT rather than TMS. D. Suicidal ideation is a manifestation of depression. TMS is prescribed as a treatment for depression and is intended to decrease suicidal ideation and other manifestations of depression such as guilt, hopelessness, sadness, and excessive crying.

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception

Correct Answer: B. Impaired judgment occurs in clients who have dementia as they lose their ability to REASON, THINK ABSTRACTLY, and have RATIONAL THOUGHTS. Incorrect Answers: A. An altered LOC is an expected finding in a client who has DELIRIUM. C. A rapid change in personality is an expected finding in a client who has DELIRIUM. D. Disturbance in perception is an expected finding in a client who has PSYCHOSIS.

A nurse is interacting with a client in the dayroom of an acute mental health facility. The client accuses the nurse of being "too bossy" and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse offer? A. "What makes you say that?" B. "Tell me what I said that made you feel uncomfortable." C. "Why are you feeling pressured by me?" D. "You shouldn't make negative statements since I'm trying to help you."

Correct Answer: B. This statement is an example of using the therapeutic technique of exploring to ask the client to explain these feelings. This can help the client view the situation objectively, which lets the nurse determine the client's thoughts and promotes trust between the client and nurse. Incorrect Answers: A. This response is nontherapeutic and may encourage the client to project blame onto others. C. This response is nontherapeutic because asking the client to explain her thoughts might be interpreted as confrontational, which can cause the client to become defensive. D. This statement is nontherapeutic because it imposes judgment and rejects the client's feelings, which can prevent further communication.

A nurse is performing a brief mental status examination for a client. To assess a client's ability to concentrate, the nurse should do which of the following? A. Point to 2 objects and ask the client to name them B. Ask the client to name the months of the year in reverse C. Say 3 words and ask the client to repeat them D. Ask the client to write a sentence

Correct Answer: B. You should evaluate the client's ability to concentrate by asking the client to name the months of the year in reverse order. Incorrect Answers: A. This method tests the client's ability to NAME OBJECTS, not the ability to concentrate. C. This method tests the client's ATTENTION and IMMEDIATE RECALL, not the ability to concentrate. D. This method tests the client's ability to use LANGUAGE, not the ability to concentrate.

A nurse in an acute substance disorder unit is assessing a client who received treatment in the emergency department for a heroin overdose. Which of the following findings should the nurse anticipate during heroin withdrawal? A. Excessive sleeping B. Muscle aches C. Pupillary constriction D. Absent bowel sounds

Correct Answer: B. You should expect the client to have muscle aches during heroin withdrawal. You should expect manifestations of withdrawal to begin within 6 - 8 hours following the last dose of heroin. Incorrect Answers: A. You should expect the client to have insomnia during heroin withdrawal. C. You should expect the client to have pupillary dilation during heroin withdrawal. D. You should expect the client to have diarrhea during heroin withdrawal

A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnosis, the nurse enters the client's room. The client begins yelling, "I've received terrible care here, and no one bothers to help me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms? A. Denial B. Displacement C. Reaction formation D. Projection

Correct Answer: B. You should identify displacement as the redirection of thoughts, feelings, and impulses from an object that causes anxiety to a safer, more acceptable one. In this scenario, the client is redirecting anxiety about the diagnosis to STAFF MEMBERS (not another person) who are providing care. Incorrect Answers: A. Denial is the refusal to accept reality while acting as if a painful event, thought, or feeling does not exist. C. Reaction formation occurs when the client exhibits a behavior or emotion that is the opposite of what the client actually feels. D. Projection occurs when the client attributes undesired impulses to another PERSON.

A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take? A. Insist that the parent tell the nurse how the child was injured B. Tell the parent that a child protective agency must be notified C. Show disapproval to the parent regarding the infant's condition D. Call at least 2 other staff members to sit in the room during the interview

Correct Answer: B. You should tell the parent that a state protective agency must be notified of the infant's condition and explain the process to the parent. Incorrect Answers: A. You should not make accusations or insist that the parent explain how the infant was injured. C. You should remain calm and professional and avoid showing emotions when interviewing the parent. D. You should not have a group of staff members present for the interview. Instead, the nurse should interview the parent in private.

A nurse is planning care for a client who has completed detoxification from opioid abuse disorder. The nurse should plan to teach about which of the following medications? A. Methadone B. Naltrexone C. Buprenorphine D. Disulfiram

Correct Answer: B. Naltrexone The nurse should plan to educate the client on naltrexone, an opioid antagonist that is used for the long-term maintenance of opioid use disorder. Naltrexone is the usual medication choice following detoxification from opioids. Incorrect Answers: A. Methadone is an opioid agonist that is prescribed as a substitute for opioids prior to detoxification. Clients must be approved by state and federal authorities to participate in methadone treatment. C. Buprenorphine is an opioid agonist-antagonist that is prescribed as a substitute for opioids prior to detoxification. D. Disulfiram is prescribed as AVERSION therapy for alcohol use disorder.

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

Correct Answer: C. Buspirone can cause xerostomia (dry mouth). Other adverse effects include HEADACHE, NAUSEA, and DIZZINESS. Incorrect Answers: A. Buspirone is more likely to cause myalgia than arthralgia. B. Buspirone is more likely to cause blurry vision than photophobia. D. Buspirone is more likely to cause tachycardia than bradycardia.

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? A. "Her mannerologies are poor." B. "My dog blank a boat to supreme heights." C. "I can play the flute while wearing a suit. You are cute." D. "My joints ache. My friend is in the joint."

Correct Answer: C. Example of clang association. Clang association refers to the use of words that are based on sound rather than meaning. A client who has schizophrenia will often use words that rhyme or have a similar beginning sound. Incorrect Answers: A. Example of neologisms (words that have meaning for the client but a different or nonexistent meaning to others). The client might use a known word differently than others understand it or create a completely new word that others do not understand. B. RN should recognize that this statement is an example of word salad. (most extreme form of associative looseness and involves a jumble of words that are meaningless to the listener when combined) D. Example of associative looseness. A common form of unusual speech patterns used by clients who have schizophrenia that results from illogical thinking and poor concentration.

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

Correct Answer: C. Greatest risk to this client is an injury from hyperactivity; therefore, the priority finding to identify is hyperactivity. You should intervene to redirect the client from unsafe activities. Constant activity can lead to exhaustion and even death. Incorrect Answers: A. Inability to concentrate indicates that the client might be unable to perform daily activities requiring concentration; however, another finding is the priority. B. Poor hygiene indicates that the client is at risk of self-care deficits; however, another finding is the priority. D. Pressured speech indicates that the client is at risk of impaired verbalization; however, another finding is the priority.

A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome (RTS)? A. Flat affect B. Refusal to accept help from others C. Report of intense guilt D. Denial of the sexual assault

Correct Answer: C. RN should expect a client who has RTS to experience guilt about the sexual assault. Feelings of guilt can delay the healing process and produce a sustained and maladaptive response. Incorrect Answers: A. Expect a client who has RTS to experience mood swings and intense emotions. B. Expect a client who has RTS to exhibit dependence toward others. D. Expect a client to express denial immediately following a sexual assault; however, this is not a characteristic of RTS.

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

Correct Answer: C. Rhinorrhea, lacrimation, pupillary dilation, yawning, and piloerection are classic manifestations of opioid withdrawal. Incorrect Answers: A. Hyperactivity is a manifestation of sedative, hypnotic, and anti-anxiety medication withdrawal. B. A headache is a manifestation of cannabis withdrawal and caffeine withdrawal. D. Tremulousness is a manifestation of alcohol withdrawal.

A nurse is assessing a client who has been taking an antipsychotic medication for 6 years. The provider has started tapering off the client's dosage. The nurse should monitor the client for which of the following manifestations of tardive dyskinesia? A. Muscular weakness B. Muscle spasms C. Involuntary tongue protrusion D. Uncontrolled rolling of the eyes

Correct Answer: C. Tardive dyskinesia begins with mouth and facial movements and progresses to involve other muscle groups. All clients receiving antipsychotic therapy for months to years are at risk. This adverse effect is potentially irreversible, and discontinuing the drug rarely relieves these manifestations. Incorrect Answers: A. Akinesia manifests as muscular weakness. This adverse effect can be noticeable 1 to 5 days after starting antipsychotic therapy and occurs most often in women, older adults, and clients who are dehydrated. B. Dystonia involves involuntary muscular movements of the face, arms, legs, and neck. Occurs most often in men and clients 25 years of age and younger. You should assess the client for dystonia in the first days of antipsychotic medication therapy. D. An oculogyric crisis is a condition in which the client has no control of rolling the eyes. This adverse effect might be mistaken for seizure activity and should be treated as an emergency situation. You should assess the client for an oculogyric crisis in the first days of antipsychotic medication therapy.

A nurse is caring for a client who is receiving treatment at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort? A. Administering an incorrect dose of benzodiazepine B. Informing the client's family member of the admission without the client's knowledge C. Informing the client that an injection will be administered if the client remains agitated D. Failing to recognize suicide risk, resulting in the client's death

Correct Answer: C. This is an example of assault. Assault is an intentional tort that is characterized by a threat toward a client that makes the client fearful of harm or unwanted touching. Incorrect Answers: A. This action is an example of negligence, which is the failure to use expected care in any situation when there is a duty to do so (unintentional tort). B. This is an example of invasion of privacy, which is a quasi-intentional tort and a violation of HIPAA. Confidential information (client's admission) should not be shared without the written consent of the client. D. This is an example of negligence. Even if negligence resulted in the client's death, this is still considered an unintentional tort.

A nurse is caring for a client who has OCD and feels compelled to pace the floor for a specific number of times each day or "something bad will happen." Which of the following responses should the nurse make? A. "Nothing terrible is going to happen to you. Please stop this behavior." B. "Are you seeking attention with this behavior?" C. "It may help if we talked about why you find it necessary to pace the floor." D. "Are you pacing to work off excess energy?"

Correct Answer: C. This response is therapeutic and encourages the client to discuss the underlying thoughts and feelings that are causing anxiety. Incorrect Answers: A. Nontherapeutic response and does not allow exploration of the client's feelings. B. Nontherapeutic response and offers a personal judgment, which does not allow exploration of the client's feelings. D. Nontherapeutic response because it makes an assumption about the client's behavior.

A nurse is assessing a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamines? A. The client exhibits paranoia B. The client reports having insomnia C. The client reports eating excessively D. The client has an increased heart rate

Correct Answer: C. When amphetamine is taken at a therapeutic dose, it causes appetite suppression. Abrupt withdrawal of amphetamine can result in abstinence syndrome in a client who is physically dependent on the medication. Indications of physical dependence include excessive eating, exhaustion, depression, prolonged sleep, and a craving for more amphetamine. Incorrect Answers: A. An adverse effect of excessive amphetamine use or acute toxicity is the development of paranoid psychosis, in which a client can experience hallucinations and paranoid delusions. The psychosis resolves following the withdrawal of the amphetamine. B. Insomnia is an adverse effect of amphetamine use at therapeutic doses. Indications of physical dependence on amphetamine can include prolonged sleep and exhaustion. D. An increased HR is a CV effect of amphetamine use caused by the release of NE. This is a pharmacological effect of the medication, not an indication of physical dependence.

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt, and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment? A. Perception of reality B. Ability to follow directions C. Physical needs D. Mental status

Correct Answer: C. When applying Maslow's Hierarchy of Needs as a priority-setting framework, you should review PHYSIOLOGICAL needs 1ST and then address the client's needs by following the remaining 4 hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with lower levels, depending on the specific client situation. Incorrect Answers: A. The client's perception of reality is important to assess in order to set realistic goals and determine safety needs; however, not the priority assessment. B. The ability to follow directions is an important part of determining the client's mental status; however, not the priority assessment. D. The client's mental status is important to determine; however, not the priority assessment.

A nurse is caring for a client with borderline personality disorder who has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups? A. Co-dependents support group B. National Alliance on Mental Illness C. Dialectical behavior treatment group D. Dual diagnosis treatment group

Correct Answer: C. You should encourage the client to participate in a DBT group that focuses on interventions for suicidal and destructive behaviors. Incorrect Answers: A. In a co-dependents support group, participants are associated with family or others who are SUBSTANCE ABUSERS. Co-dependents support and enable the substance abuser by excusing their lack of responsibility for their behavior. B. The National Alliance on Mental Illness is a consumer support and advocacy organization that evaluates services provided to those with serious mental illness. D. In a dual diagnosis treatment group, participants have a mental illness diagnosis along with a SUBSTANCE USE DISORDER Dx.

A nurse is providing teaching to a client who has GAD and a new Rx for buspirone. Which of the following manifestations is a common adverse effect of this medication? A. Confusion B. Bradycardia C. Dizziness D. Insomnia

Correct Answer: C. You should inform the client that dizziness is a common adverse effect of buspirone. You should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects has been determined. Incorrect Answers: A. Confusion is NOT an adverse effect of buspirone, although the client might experience decreased concentration and headaches. B. TACHYCARDIA and PALPATIONS are possible adverse effects of buspirone. D. Drowsiness, NOT insomnia, is an adverse effect of buspirone.

A nurse is teaching a client who wants to stop smoking by using nicotine lozenges. Which of the following statements should the nurse make? A. "Drink water directly before taking the lozenge." B. "Place the lozenge under your tongue and let it dissolve." C. "Limit your use to no more than 20 lozenges per day." D. "Take 2 4-mg lozenges right after waking up in the morning."

Correct Answer: C. You should instruct the client NTE 5 lozenges within 6 hours and NTE 20 lozenges/day. Incorrect Answers: A. You should instruct the client to not eat or drink anything 15-20 min PRIOR to using a lozenge or WHILE the lozenge is in the mouth. B. You should instruct the client to place the lozenge in the mouth and allow it to dissolve (take 20-30 minutes to dissolve). D. Lozenges are available in 2 strengths (2 & 4mg). A client who begins smoking 30 minutes or more AFTER waking should take a 2-mg lozenge. A client who begins smoking sooner should take a 4-mg lozenge. Adverse effects can occur if 2 lozenges are taken at the same time.

A nurse is providing teaching to a client who has insomnia. Which of the following statements should the nurse make? A. "Limit daytime napping to an hour maximum." B. "Watch TV as you fall asleep." C. "If you aren't able to sleep, you can get out of bed and read a book." D. "Track the number of hours that you sleep each night."

Correct Answer: C. You should instruct the client to get out of bed and participate in a quiet activity such as reading until he feels sleepy, at which time he should return to bed. Incorrect Answers: A. You should instruct the client to avoid daytime napping whenever possible. If a nap is required, it should be limited to 20-30 min max. B. You should instruct the client not to watch television or use any other electronic devices while trying to go to sleep. Sleep hygiene is supported by the reduction of stimuli. D. You should instruct the client to monitor the QUALITY of sleep and rest rather than the number of hours (quantity). Focusing on the numbers of hours slept can increase the client's insomnia.

A nurse is counseling a client who seems relaxed initially but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make? A. "Did I say something wrong that made you feel tense?" B. "Do you often feel tense when you are talking to a health care provider?" C. "What were we discussing when you began to feel uncomfortable?" D. "It's okay to feel nervous during our counseling sessions."

Correct Answer: C. You should use the therapeutic technique of focusing, which promotes discussion about a specific topic and helps identify the cause of the client's feelings. Incorrect Answers: A. B. You should avoid using closed-ended questions that block client communication. D. You should avoid providing approval for and assuming the cause of the client's feelings. These responses are nontherapeutic and block client communication.

A nurse is preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take? A. Make sure the caregiver is present when interviewing the client B. Document how the caregiver responds when told that the client looks neglected C. Ask the client why she refuses to eat the caregiver's food D. Identify sources of stress for the caregiver

Correct Answer: D In addition to collecting information from the client, you should interview the caregiver and should ask about sources of stress. It is important to gain an understanding of the social environment of the home to identify needed changes that may improve care for the client. Incorrect Answers: A. You should interview the client in private and should work to establish a trusting nurse-client relationship to put the client at ease during care. B. You should avoid trying to prove maltreatment by making accusations, placing blame, or judging because these actions decrease trust. If maltreatment is suspected by the nurse following an assessment, the nurse has the duty to report the situation to adult protective services. C. This question could cause the client to feel at fault or in trouble and should be avoided. You should use open-ended statements and questions to obtain information from the client.

A nurse on a mental health unit is caring for a client who begins throwing objects at other clients. Which of the following actions is the priority nursing intervention? A. Attempt to restrain the client's arms B. Administer an anti-anxiety medication C. Place the client in seclusion D. Tell the client to stop the behavior

Correct Answer: D When providing client care, you should first use the least restrictive intervention; therefore, you should talk to the client to encourage her to calm down and prevent harm to others. Incorrect Answers: A. You might have to attempt to restrain the client to encourage her to calm down and prevent harm to others; however, you should use a less restrictive intervention first. B. You might have to administer an anti-anxiety medication to encourage the client to calm down and prevent harm to others; however, you should use a less restrictive intervention first. C. You might have to place the client in seclusion to encourage her to calm down and prevent harm to others; however, you should use a less restrictive intervention first.

A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? A. Obtain a PRN prescription for restraints from the client's provider. B. Visually observe the client every 10 min until restraints are removed. C. Ensure 3 fingers can fit between the restraint and the client's wrist. D. Document the client's behavior every 15 min while restraints are in place.

Correct Answer: D You should plan to document the client's behavior q15 min while restraints are in place to meet the legal requirement for use of restraints. This documentation allows prompt identification of complications r/t restraint use and helps ensure that restraints are removed ASAP, depending on the client's behavior. Incorrect Answers: A. You should obtain a Rx for restraints from the HCP; however, this Rx is legally required to be current and specific to the client's present needs rather than PRN. B. You should plan for 1-on-1 observation by staff while the client is in restraints. C. You should ensure 2 (TWO) fingers can fit between the restraints and the client's wrist (safety check promotes adequate circulation while maintaining the effectiveness of the restraint).

A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? A. The client requires assistance with eating. B. The client independently manages personal finances. C. The client has bladder incontinence. D. The client is able to identify the names of family members.

Correct Answer: D You should expect this client who has Stage 4 Alzheimer's disease to recognize and identify family members. Clients who have Alzheimer's disease maintain this ability until STAGE 6. Incorrect Answers: A. A client with Stage 4 Alzheimer's disease will still have the ability to eat without assistance. Clients who have Alzheimer's disease maintain this ability until STAGE 7. B. A client with Stage 4 Alzheimer's disease will have DIFFICULTY performing COMPLEX tasks such as managing personal finances. C. A client with Stage 4 Alzheimer's disease will be able to use the toilet independently. Clients who have Alzheimer's disease maintain continence until STAGE 6.

A nurse is providing teaching to a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make? A. "You will get very sick if you drink alcohol while taking this medication." B. "The medication will be administered as a subcutaneous injection." C. "You should take this medication on an empty stomach." D. "The medication might cause you to have episodes of diarrhea."

Correct Answer: D. Instruct the client that an adverse effect of acamprosate is diarrhea. Incorrect Answers: A. Instruct the client that acamprosate reduces the unpleasant feelings associated with abstinence such as anxiety, dysphoria, and tension. Unlike disulfiram, acamprosate does NOT function as aversion therapy. B. Instruct the client that acamprosate is administered orally in delayed-released tabs. C. Instruct the client to take 2T PO TID WF. Taking around mealtimes helps promote compliance.

A nurse is caring for a client who has schizophrenia and is being discharged from an acute mental health setting. Which of the following should be included in the discharge plan? A. Refer the client to respite care services B. Provide a list of primary preventive mental health groups C. Enroll the client in a 12-step program D. Contact an intensive outpatient program

Correct Answer: D. A client who has received in-patient treatment for schizophrenia can benefit from an intensive outpatient program. These programs allow clients to receive step-down care similar to what was provided in the inpatient setting to stabilize their condition further. Incorrect Answers: A. Respite care is designed to serve people who are caregivers in the home for those who are ill or disabled (e.g. Alzheimer's disease). B. Primary preventive services are designed to help clients PRIOR to the manifestations of illness. Tx with primary prevention services can delay or prevent disorders from occurring. C. Twelve-step programs are support groups that help clients overcome addiction from substance abuse disorders. These programs are not designed to support clients who have schizophrenia.

A nurse is teaching a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make? A. "Schedule 20 minutes of aerobic exercise during the hour before bedtime." B. "Eliminate all caffeinated beverages from your diet." C. "Sleep for extra time when you can." D. "Eat a light snack containing carbohydrates before bedtime."

Correct Answer: D. A light snack consisting of a carbohydrate-based food or milk can help promote sleep when ingested before bedtime. Consuming heavy meals just before sleeping can promote insomnia. Incorrect Answers: A. The client should exercise 3 hours or more before bedtime to avoid sleep interruption. Moderate aerobic activity for about 20 minutes earlier in the day has been shown to reduce stress and prevent insomnia. B. Beverages containing caffeine can cause insomnia and tachycardia and increase anxiety. Clients who drink more than 4 caffeinated beverages daily should be instructed to decrease their use slowly to prevent withdrawal manifestations such as headaches and irritability. C. Sleeping for extra time can cause sleep disruptions and increased fatigue. Instruct client to keep a consistent sleep schedule regarding bedtime and waking time.

A home health nurse is assessing a client who has advanced dementia and whose caretaker recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse make a referral for this client? A. Partial hospitalization B. Adult day care facility C. Inpatient geropsychiatric unit D. Long-term care nursing center

Correct Answer: D. A long-term care nursing center provides intermediate or custodial care for clients who have acute or chronic illnesses. A client who has advanced dementia is a candidate for a SNF because the client needs 24-hour nursing care and support. Incorrect Answers: A. Partial hospitalization programs are recommended for ambulatory patients who DO NOT require 24-hour nursing care. A client who has advanced dementia requires constant supervision and assistance. B. Adult daycare facilities provide custodial care for clients during the day. At night, clients then return to their own home where they are under the care of a caregiver. Since this client no longer has a caregiver available, this is not an appropriate referral. C. A geropsychiatric unit is primarily for clients who have mental illness and might harm themselves or others. These clients are provided with inpatient treatment and medication adjustment with the GOAL of DISCHARGE when the clients are stable.

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of this medication every 72 hr C. Offer the client a PRN NSAID while taking this medication D. Administer the medication at bedtime

Correct Answer: D. Donepezil is used to treat the manifestations of mild to moderate Alzheimer's disease. The nurse should administer this med HS to reduce the risk of injury due to bradycardia and syncope. Incorrect Answers: A. You should monitor liver function for a client who is taking the cholinesterase inhibitor tacrine; however, donepezil is a med that is NOT hepatotoxic. B. You should expect the HCP to increase the client's dosage gradually until a therapeutic effect is achieved; however, an increase is not expected until the client has been taking the medication for 4-6 weeks. C. You should inform the client of the risk of GI bleeding while taking this med. Taking donepezil concurrently with an NSAID increases this risk.

A nurse is planning care for a client who is scheduled to undergo ECT. Which of the following interventions should the nurse include? A. Maintain a clear liquid diet for 6 to 8 hr prior to ECT B. Allow the client to sleep for 3 to 4 hr following ECT C. Administer IM epinephrine to the client prior to ECT D. Reorient the client to the environment after ECT

Correct Answer: D. Due to a transient period of confusion after ECT, plan to reorient the client following ECT. Incorrect: A. The client should be NPO for 6 to 8 hours before the ECT procedure and can eat after awakening from the treatment. B. Expect the client to awaken about 15 minutes after the ECT treatment. A short-acting general anesthetic and a muscle relaxant will be administered prior to the Tx, which will allow the client to awaken quickly when the Tx is completed. C. Expect to administer a medication like atropine prior to ECT. Atropine decreases oral secretions and counteracts bradycardia, which can occur due to vagal stimulation. Epinephrine is prescribed to treat anaphylaxis and is NOT used prior to ECT.

A nurse is assessing a client who is experiencing PTSD following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe? A. Bupropion B. Phenelzine C. Mirtazapine D. Paroxetine

Correct Answer: D. Expect the provider to prescribe paroxetine (SSRI) that is considered the first-line treatment for PTSD. Incorrect Answers: A. Bupropion is an aminoketone antidepressant that is prescribed for smoking cessation, depression, and treatment of ADHD (not prescribed for PTSD treatment) B. Phenelzine (MAOI) that can be prescribed for PTSD. However, SSRIs (e.g., paroxetine) are first choice for PTSD. C. Mirtazapine (TCA) can be prescribed for PTSD. However, SSRIs such as paroxetine are the first choice for PTSD.

A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders? A. Paranoid B. Histrionic C. Antisocial D. Schizotypal

Correct Answer: D. Findings of schizotypal personality disorder include a pattern of social impairments and cognitive alterations, including superstitious actions that are not congruent with the client's cultural norms and speech changes (e.g. an increase in the use of metaphors and other elaborate speech patterns). Incorrect Answers: A. You should identify extreme suspicion of others, difficulty trusting, and a persistent unwillingness to forgive as findings of paranoid personality disorder. B. You should identify excessive attention-seeking behaviors and rapidly shifting emotions as findings of histrionic personality disorder. The client might dress in a manner that attracts attention and show dramatic behavior. C. You should identify behaviors that exhibit disregard for the rights and feelings of others as indications of antisocial personality disorder. The client might exhibit deceitfulness, aggressiveness towards others, and a reckless lack of concern for the safety of self or others.

A nurse is providing teaching to the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by the family 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."

Correct Answer: D. It is common following ECT for a client to experience confusion and disorientation. Incorrect Answers: A. You should explain to the family that confusion and disorientation often occur following ECT. Memory deficits might also be present. In rare cases, death has occurred from acute MI or cerebrovascular accident. B. You should explain to the family that memory deficits (shortfalls) do NOT always recover following ECT. C. Persistent cardiac dysrhythmias are NOT an adverse effect of ECT.

A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision

Correct Answer: D. Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria. Incorrect Answers: A. Muscle weakness and fine hand tremors are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 and 1.5 mEq/L. B. Manifestations of lithium toxicity with levels above 2.5 mEq/L include seizures and oliguria. For levels above 3.5 mg/dL, delirium, cardiovascular collapse, coma, and death can occur. C. Nausea, vomiting, diarrhea, and lethargy are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 and 1.5 mEq/L.

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

Correct Answer: D. Short-term memory loss is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality. Incorrect Answers: A. Clients who have moderate cognitive decline become disoriented to time, places, and events. B. Clients who have moderate cognitive decline lose their ability to handle money and finances. They also begin to have difficulty using language. C. Clients who have moderate cognitive decline withdraw from socializing and become self-absorbed (preoccupied with one's own feelings, interests, or situation).

A nurse is providing teaching to the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will not set time limits for discussing her delusions." B. "We will avoid reacting to her command hallucinations." C. "She might lose weight due to her medications." D. "She might be having a relapse if she stops attending social events."

Correct Answer: D. The family of a client who has schizophrenia should be taught the signs of relapse, including avoiding other people, sleep disturbances, difficulty concentrating, and being unable to tell reality from nonreality. Incorrect Answers: A. The family of a client who has schizophrenia should be taught not to allow the client to dwell excessively on her delusions. Time limits should be set, and the focus of the conversation should be reality-based. B. The family of a client who has schizophrenia should be taught that it is important to find out what the client hears the voices say. The client might hear the voices directing her to hurt herself or someone else. C. The family of a client who has schizophrenia should be taught that an adverse effect of antipsychotic medications is weight gain. The family should encourage the client to exercise and follow a low-calorie diet.

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."

Correct Answer: D. 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. Incorrect Answers: A. This response is disagreeing, which can make the client defensive and feel a sense of rejection. It is a form of nontherapeutic communication that implies the client's statement is inaccurate. The client is likely to discontinue further interaction with the nurse, preventing the development of a therapeutic nurse-client relationship. B. This response is changing the subject, which can invalidate the client's feelings and needs. With this response, the nurse is taking over the conversation, which can result in the client discontinuing further interaction with the nurse. C. This response is interpreting the client's meaning into something that seems more plausible to the nurse. This invalidates the client's thoughts and statements, which is nontherapeutic.

A nurse is determining the total score for a client's Alcohol Use Disorders Identification Test (AUDIT) by assigning a score of 0 to 4 for each answer. For which of the following self-reported findings should the nurse assign the client a score of 4? A. The frequency of alcohol intake is typically 3 times per week. B. The client misses work once a month because of alcohol intake. C. Alcohol intake does not cause the client to have feelings of guilt. D. Last month, the provider suggested the client should reduce alcohol intake.

Correct Answer: D. When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 4 if the client indicates that a friend, relative, or HCP has recommended decreasing alcohol consumption at least once during the last 12 months. Incorrect Answers: A. When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 3 if the client indicates a frequency of alcohol intake of 2-3 times per week. B. When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 2 if the client indicates missing work or failing to fulfill obligations once a month because of alcohol intake. C. When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 0 if the client DENIES feelings of guilt because of alcohol intake.

A nurse is providing teaching to a client about cannabis use disorder. Which of the following client statements indicates an understanding of the teaching? A. "Withdrawal of cannabis occurs 3 days after cessation." B. "There are no physical manifestations of withdrawal from cannabis." C. "Drug screens can detect cannabis for up to 8 weeks after use." D. "Cannabis use can produce effects resembling the effects of alcohol use."

Correct Answer: D. You should explain to the client that, when used moderately, cannabis produces effects resembling the effects of alcohol and other CNS depressants. By depressing higher brain centers, CNS depressants release lower centers from inhibitory influences. Incorrect Answers: A.B. You should explain to the client that physical manifestations of cannabis withdrawal include abdominal pain, shakiness, sweating, fever, chills, and headaches. C. You should explain to the client that drug screens can detect cannabis for up to 4 weeks after use.

A nurse is assessing a client with psychotic disorder who has a new prescription for haloperidol. The client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is this client likely experiencing? A. Dystonia B. Parkinsonism C. Tardive dyskinesia D. Akathisia

Correct Answer: D. Akathisia Akathisia is an extrapyramidal adverse effect characterized by a sense of inner restlessness and observable behaviors such as pacing, rocking forward and backward in a chair, and constant foot tapping. Incorrect Answers: A. Dystonia is an extrapyramidal adverse effect characterized by muscle spasms, not motor restlessness. B. Parkinsonism is an extrapyramidal adverse effect characterized by manifestations that resemble those seen in Parkinson's disease such as shuffling gait, drooling, and stooped posture. C. Tardive dyskinesia is an irreversible finding characterized by involuntary movements of the extremities.

A charge nurse on the mental health unit is making shift assignments to best utilize the team and implement effective care. The staffing for the shift includes a practical nurse (PN) and an AP. Which of the following tasks should the nurse delegate to the PN? 1 Creating a care plan for a client who has schizophrenia 2 Weighing a client who has bulimia nervosa 3 Reinforcing teaching about medications for a client who has depression 4 Recording the intake of a client who is experiencing mania

3 Reinforcing teaching about meds for a client who has depression is within the scope of practice for a LPN. Therefore, the RN should delegate this task to the PN. NOT 1 Creating a plan of care for a client who has schizophrenia is not within the scope of practice for a LPN. Assessments and planning care are the responsibility of the RN. 2 Within the range of function for an AP. (RN should delegate this task to the AP) 4 Within the range of function for an AP. It is important to maintain an accurate account of the client's I&Os, and calorie count. (RN should delegate this task to the AP)

Phentolamine (Regitine)

-alpha blocker that reduces peripheral vascular resistance and is also used to treat HTN. -Like phenoxybenzamine, it is used to treat the high BP (i.e., HTN crisis from MAOIs) -Most often used to treat the extravasation of vasoconstriction drugs such as norepi, epi, and dope, which when given IV can leak out of the vein esp if the IV tube is not correctly positioned. -Contraindicated in hypersensitivity, MI, and those with CAD. -Adverse effects include: tachycardia, dizziness, GI upset.

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? 1 Total body fat 8.7% 2 Potassium 3.6 mEq/L 3 Temperature 36.1° C (96.9° F) 4 Heart rate 54/min

1 The RN should recognize criteria for hospitalization includes having a weight < 75% of ideal body weight, or < 10% body fat. (RN should report finding to HCP) NOT 2 WNL 3 Criteria for hospitalization include a temperature < 36° C or 96.8° F 4 Criteria for hospitalization is a HR < 50/min during the daytime.

A nurse in an outpatient facility is delegating tasks to an AP. Which of the following task should the nurse delegate to the AP based on client needs? 1 Providing telephone advice about rehabilitation facilities 2 Performing basic life support for a client who has depressive disorder and no pulse 3 Instructing a client how to collect a urine sample for drug screening 4 Giving two acetaminophen to a client who reports a headache because of antipsychotic medication

2 Performing basic life support (CPR) for a client who has no pulse is within the range of function of an AP. The AP should initiate CPR and call for assistance. NOT 1 Providing telephone advice about rehabilitation facilities is not within the range of function of an AP. 3 Instructing a client how to collect a urine sample for drug screening is not within the range of function of an AP. 4 Giving a client who reports a headache because of antipsychotic medication two acetaminophen is not within the range of function of an AP.

Disulfiram-Alcohol Reaction

A disulfiram-alcohol reaction is manifested by hyperventilation, dizziness, vomiting, and hypotension.

Psychosis

A general term describing an inconsistent and variable thought process. Includes hallucinations, delusions, lack of insight "psykhe" meaning "mind" + "-osis" meaning "abnormal condition" = "abnormal condition of the mind"

A RN in an acute care facility is planning discharge for a client who has alcohol use disorder and recently experienced alcohol withdrawal with severe serious complications. The client requires continued nursing care and supervised medication monitoring. Which of the following resources should the nurse recommend? 1 An intensive outpatient program 2 Standard outpatient treatment 3 A residential halfway house facility 4 A residential rehabilitation facility

4. A residential rehabilitation facility provides around-the-clock RN care and supervised medication monitoring, as well as short-term or long-term rehabilitation for lost physical or mental function. (appropriate referral for RN to make) NOT 1 An intensive outpatient program includes scheduled individual & group therapy sessions for about 3days / week. Supervised medication monitoring is not included. (client requires different type of Tx program) 2. Standard outpatient Tx includes scheduled appointments for Tx groups and individual client therapy; however, supervised medication monitoring and nursing care is not included. (client requires different type of Tx program) 3. A halfway house facility helps clients who are ready to learn new life skills but no longer need nursing care or supervised medication monitoring. (client requires different type of Tx program)

Rhinorrhea, lacrimation, pupillary dilation, yawning, and piloerection are manifestations of what type of withdrawal?

Classic manifestations of opioid withdrawal.

Schizoid Personality Disorder

A personality disorder characterized by persistent avoidance of social relationships and little expression of emotion

Rape trauma syndrome (RTS)

A related to post-traumatic stress disorder but is more specific to sexual assault. RTS describes symptoms of trauma including disruptions to normal physical, emotional, cognitive and interpersonal behavior.

Dementia

A slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes

Agraphia

AGRAPHIA is the decreasing ability to READ or WRITE.

Agnosia

Agnosia is the loss of the sensory ability to recognize objects. This is often exhibited by clients who have lost the ability to recognize familiar sounds or people. "a" meaning "without" + "gnosis" meaning 'knowledge" = agnosia = ignorance (greek)

Akathisia

Akathisia is an extrapyramidal adverse effect characterized by a sense of inner restlessness and observable behaviors such as pacing, rocking forward and backward in a chair, and constant foot tapping. "A" meaning "not" + "Kathízein" meaning "to sit" = "inability to sit"

Akinesia

Akinesia manifests as muscular weakness. This adverse effect can be noticeable 1 to 5 days after starting antipsychotic therapy and occurs most often in women, older adults, and clients who are dehydrated.

Assertive Community Treatment (ACT)

An intensive type of case management for people with serious, persistent psychiatric symptoms. Repeated hospitalizations are reduced through a multidisciplinary team that provides a comprehensive array of services. EBP indicates the nurse should 1st refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so inpatient hospitalizations can be avoided.

A nurse is teaching a client who has major depressive disorder and is scheduled to begin ECT. Which of the following pieces of information should the nurse include? A. "If you're taking a benzo med, you should take it before the procedure." B. "You can expect to wake up about 15 minutes after the procedure." C. "After the first procedure, you should expect to have ECT sessions monthly for a year." D. "ECT is the primary treatment for most clients who have depression."

Answer: B. A client who undergoes ECT usually wakes up about 15 min after the procedure and can be disoriented for several hours after. Incorrect: A. ECT deliberately causes seizures, and benzo use prevents therapeutic seizure activity. Therefore, the client should NOT take benzos before ECT. C. ECT is typically prescribed 2-3x/week for approximately 6-12 treatments total. D. Medication is the primary treatment for most clients who have depression. ECT might be the first-line treatment in specific situations such as delusional depression or if a client cannot take meds due to other medical problems.

Atropine: Class, Indications, MOA, Effects

Anticholinergic Symptomatic bradycardia, organophosphate poisoning, hypersalivation, bronchial secretions Atropine competitively blocks the effects of acetylcholine Decrease secretions ("secretions are mine"), increases HR, and improves the AV conduction by blocking the parasympathetic influences on the heart.

Antipsychotic medications are contraindicated for what type of client?

Antipsychotic medications are contraindicated for clients with dementia because they increase the risk of death.

Apraxia

Apraxia is the loss of purposeful movement in the ABSENCE of motor or sensory impairment. This is often exhibited by clients who are unable to perform once-familiar tasks. "a" meaning "without" "praxis" meaning "action"

Avolition

Avolition is a lack of motivation. It is a negative manifestation of schizophrenia. "a" meaning "without" "volition" meaning "to will" or "to wish"

Common manifestations of lithium levels between 2 and 2.5 mEq/L

Blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria are common manifestations of lithium toxicity levels between 2 and 2.5 mEq/L

A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? A. Request a prescription for an antianxiety medication B. Provide the client with a stimulating activity prior to bedtime C. Dim the lights in the client's room at night D. Encourage the client to make decisions about her daily routine

Correct Answer: A You should request a Rx for an antianxiety med for a client who develops delirium. Administration of a PRN antianxiety medication can decrease anxiety and agitation. Incorrect Answers: B. You should maintain a low-stimulation environment for the client to DECREASE DISORIENTATION due to overstimulation. C. You should keep the client's room WELL-LIT (not dimmed). Adequate lighting can help the client remain oriented to place upon waking at night and will promote safety if the client becomes ambulatory. D. You should provide a consistent routine and limit the client's need to make decisions. These actions will decrease disorientation and anxiety.

A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. Which of the following statements should the nurse offer? A. "We'll assist you with making decisions." B. "Someone will work with you when you have flashbacks." C. "You'll be going through aversion therapy to help you cope." D. "The therapy will help you control your impulses."

Correct Answer: A. Clients who have GAD are often indecisive and dread making decisions. Therefore, you should reassure the client that help will be provided with making decisions. Incorrect Answers: B. Clients who have PTSD experience flashbacks; this would not be necessary for a client who has GAD. C. Clients who have behaviors that might not be successfully treated by other methods, such as alcohol use disorder or aggression, can benefit from aversion therapy. Aversion therapy is NOT a treatment method for clients who have GAD. D. Clients who have OCD often have difficulty controlling impulses; this would not be necessary for a client who has GAD.

A nurse at a long-term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements should indicate that the AP requires further teaching? A. "We will be serving breakfast in 10 min. I will stay here while you get ready." B. "It's Monday morning. I know that your favorite television shows are on this evening." C. "I see that you have a new photo on the wall. Can you tell me who that girl is?" D. "It's almost time for your appointment. Let me do your hair for you and brush your teeth."

Correct Answer: D. When a client with dementia has periods of confusion, the AP should give the client additional time to complete activities that can be performed independently. Insisting on completing the task or attempting to hurry the client can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or truly needs it. Incorrect Answers: A. This statement orients the client to the day and time and offers her social support while getting ready. B. This statement orients the client to the day and time and offers contextual clues about the environment. C. This statement gives the client contextual clues about the environment and shows an interest in her life. This type of conversation helps orient the client.

Common manifestations of lithium levels above 2.5 mEq/L or 3.5 mg/dL

Manifestations of lithium toxicity with levels above 2.5 mEq/L include seizures and oliguria. For levels above 3.5 mg/dL, delirium, cardiovascular collapse, coma, and death can occur.

Maslow's Hierarchy of Needs

Maslow's Hierarchy of Needs, which includes 5 levels of priority: 1. Physiological needs 2. Safety and security needs 3. Love and belonging needs 4. Personal achievement and self-esteem needs 5. Achieving full potential while problem-solving and coping with life situations

Remote memory

Memory for experiences in the distant past Very long-term recall

Echopraxia

Mimicry or imitation of the movements of another person. 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.

Common manifestations of lithium levels between 1.0 and 1.5 mEq/L.

Muscle weakness, fine hand tremors, NV, diarrhea, and lethargy are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 and 1.5 mEq/L.

Heroin

Narcotic drug derived from opium that is extremely addictive

Acute Dystonia

Dystonia is an extrapyramidal adverse effect characterized by muscle spasms, not motor restlessness. Acute dystonia is manifested by severe muscle spasms that often occur in the head and neck, not writhing movements

Schizotypal Personality Disorder

Findings of schizotypal personality disorder include a pattern of social impairments and cognitive alterations, including superstitious actions that are not congruent with the client's cultural norms and speech changes (e.g. an increase in the use of metaphors and other elaborate speech patterns).

Parkinsonism

Parkinsonism is an extrapyramidal adverse effect characterized by manifestations that resemble those seen in Parkinson's disease such as shuffling gait, drooling, and stooped posture (bent forward and down at the waist and/or mid-back while maintaining straight legs).

Schizoid vs. Schizotypal

Schizoid: loner, unemotional; Schizotypal: Eccentric with odd thoughts/behavior

Tardive dyskinesia

Tardive dyskinesia is a disorder that results in involuntary, repetitive body movements, which may include grimacing, involuntary tongue protrusion, or smacking the lips. You should report these manifestations to HCP immediately. Fiterm-3ndings might not be reversible and can progress to affect all extremities. [-dys-] meaning "abnormal" [-kin-] meaning "movement" [-esia] meaning "condition" or "situation".

methylphenidate IR: effects, dose,

The nurse should instruct the parent that an adverse effect of methylphenidate is growth suppression related to the appetite suppression associated with the medication. Administering the medication with or after meals will help protect the child's appetite. Has a dosing schedule of 2 to 3 times daily. Sustained-release methylphenidate is taken once or twice daily. There are also 24-hour formulations of methylphenidate that are taken once each morning.

Restructuring and ADHD

The nurse should instruct the parents about the use of restructuring, which adjusts or changes an activity based on the child's level of frustration.

Planned ignoring and ADHD

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

A nurse is 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 RN? 1 Schedule the client for group therapy sessions. 2 Maintain consistent rules 3 Provide frequent high-calorie snacks 4 Avoid the use of value judgments.

3 Priority action the RN is to meet the client's need for adequate nutrition. Providing high-calorie snacks is the priority action for the nurse to take. NOT 1 RN should incorporate group therapy. However, this is not the priority action for the nurse to take. 2 RN 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. 4 RN should avoid value judgments to minimize escalating mania. However, this is not the priority action for the nurse to take.

Dialectical behavior therapy (DBT)

A treatment often used for borderline personality disorder that incorporates both cognitive-behavioral and mindfulness elements. Dialectical behavior therapy (DBT) is a modified type of cognitive-behavioral therapy (CBT). Its main goals are to teach people how to live in the moment, develop healthy ways to cope with stress, regulate their emotions, and improve their relationships with others.