Mental Health Exam 3

The nurse is educating a pregnant client about prenatal care and the potential for decreasing the risk for conduct disorder. The client presently has a child with a conduct disorder and is concerned that this will happen again. Which statement made by the client indicates further education is required?

"As long as I only have a beer or two a couple of times a week, my unborn child will be ok." Explanation: The pregnant female demonstrates further education is required when discussing that it is acceptable for them to drink any alcohol with a growing fetus. It is shown that prenatal alcohol use causes an increased risk for the development of a conduct disorder. Being adherent to prenatal vitamins and folic acid place the fetus in the optimal state of preventable health issues, such as neural tube defects. Attending prenatal care visits routinely can help identify issues in the early developmental states. There are behavioral, prenatal, and environment that may contribute to the development of a conduct disorder.

A nurse tells the child and caregiver that the nurse will interview each of them separately. The caregiver questions why this needs to occur. What is the nurse's best response?

"Both interviews provide unique and meaningful information." Explanation: To get an accurate picture of the child, the nurse should interview the child and parent individually because each can provide unique meaningful information. Research has shown that when parent and child are interviewed separately the children provide information about internalizing symptoms and the parents provide information about externalizing symptoms.

A bipolar client presents to the clinic with reports of headaches and feeling more irritable than usual. What is the best nursing response?

"Can you tell me more about these symptoms?" Explanation: Additional assessment is needed for the bipolar client at this time. By asking an open-ended question, the nurse will be able to determine if the symptoms described by the client are examples of a depressive episode. Telling the client to continue taking medication as prescribed may be warranted, but telling the client that the symptoms are minor minimizes the expressed concern. Asking the client whether or not they have been taking their medication correctly may be needed but it is not the best response at the time because it can be construed as implicit bias. There may be a need for bloodwork, but more information is needed before an order should be obtained.

A client with mania attempts to hit the nurse during a conversation. Which is the best response by the nurse?

"Do not swing at me again. If you cannot control yourself, we will help you." Explanation: "Do not swing at me again. If you cannot control yourself, we will help you," firmly states behavioral expectations, limit setting, and lets the client know their behavior will be safely controlled if they are unable to do so. Arguing that the nurse does not deserve the attack provokes confrontation rather than communicating clear expectations. Stating "If you do that one more time, you will be put in seclusion immediately" is likely to be perceived as a threat rather than an assertive statement. Similarly, stating "Why do you continue that kind of behavior? You know I won't let you do it" may be perceived as a challenge or threat.

After educating a client with bipolar disorder on his prescribed lithium therapy, the nurse determines that additional education is needed when the client states which of the following?

"I need to cut back on my salt intake when it's really hot outside." Explanation: Clients should increase their intake of salt during periods of perspiration (e.g., when it is hot outside) and periods of increased exercise and dehydration. Severe diarrhea and slurred speech suggest moderate toxicity, which needs to be evaluated. Alcohol interacts with lithium, causing increased serum concentrations of the drug, placing the client at risk for toxicity. Sugarless candies and throat lozenges can help to combat metallic taste.

During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which is the mostappropriate statement by the nurse?

"Let's go to the conference room and talk for a while." Explanation: Redirecting the client to a quieter, smaller room will decrease external stimuli and promote calmness so the client will eventually rest and sleep. It is more effective and therapeutic for the nurse to suggest an alternative rather than adopting a reprimanding or confrontational tone. Making a new suggestion is likely more effective than asking a client who is manic to simply stop what they are doing. Stating "turn down the radio" is more likely to provoke a confrontation than suggesting that they go to a different room. The client is manic, so is unlikely to respond to a reason-based argument about the need for rest.

The nurse is assessing a 2-year-old child during a wellness checkup. Which statement(s) by the parent indicate that the child needs to be screened for autism spectrum disorder?

"My child rarely makes eye contact with me or siblings." "I notice that my child has very few facial expressions to situations." "There is no spontaneous play at all and will only plays with one object." Explanation: Children with autism display little eye contact with and make few facial expressions toward others; they use limited gestures to communicate. They have limited capacity to relate to peers or parents. They lack spontaneous enjoyment, express no moods or emotional affect, and cannot engage in play or make-believe with toys. These children engage in stereotyped motor behaviors such as hand flapping, body twisting, or head banging. Children with autism spectrum disorder prefer routines and tend not to respond to questioning.

A 9-year-old client with attention deficit hyperactivity disorder (ADHD) has been placed on the stimulant methylphenidate. The nurse knows that the teaching has been effective when the client's parents make which statement?

"Our child may have some side effects, like insomnia, loss of appetite, or weight loss." Explanation: The most common side effects of common medications used to treat ADHD, such as methylphenidate, include insomnia, loss of appetite, and weight loss or failure to gain weight. Methylphenidate is not taken every 12 hours; it is available in a sustained-release form taken once daily or in a daily transdermal patch, or it is given in 3 or 4 divided doses a day. Methylphenidate begins to have an effect within about 30 minutes. The client does not need to have blood drawn weekly.

A 10-year-old child with Tourette's disorder is receiving haloperidol as part of his treatment plan. When assessing the child at a follow up visit, which statement by the child would lead the nurse to suspect that he is experiencing a side effect of the drug?

"Sometimes I feel like I'm so sleepy." Explanation: The most frequently encountered side effects associated with medication therapy such as haloperidol include drowsiness, dulled thinking, muscle stiffness, akathisia, increased appetite and weight gain, and acute dystonic reactions.

The nurse working in a behavioral health unit is talking with an LPN regarding a client that is on suicide precautions. Which statement by the LPN requires correction by the nurse?

"The client only talked about killing themselves, they probably will never do it." Explanation: Suicidal people often send out subtle or not-so-subtle messages that convey their inner thoughts of hopelessness and self-destruction. Both subtle and direct messages of suicide should be taken seriously with appropriate assessments and interventions. The misconception by the LPN should be corrected and reeducation should take place. Making sure the environment is safe and there is nothing that can cause potential harm is important to protect the client. The LPN should not fear talking about or saying the term "suicide." Encouraging the client to engage in an activity and spend some extra time with them is a positive intervention to strengthen the nurse-client relationship.

A nurse is providing care to a child with Tourette disorder. In teaching the parent about the disorder and treatment, what will the nurse teach about the medication?

"The condition is treated with atypical antipsychotic medication." Explanation: The correct response is that Tourette disorder will be treated with an atypical antipsychotic medication. The use of atypical antipsychotics such as risperidone and aripiprazole is replacing the use of older antipsychotics, haloperidol, and pimozide and have better results. Psychostimulants are used in treatment of ADHD and would not be used to treat this disorder. Mood antipsychotics are used in the treatment of bipolar disorder and not Tourette disorder and the symptoms of the disease are not the same. The use of antidepressants are used in the treatment of major depression, not Tourette disorder. Atypical antipsychotics have been useful in the treatment of depression.

A nurse working with children with autism spectrum disorder (ASD) hears an unlicensed assistive personnel (UAP) stating, "I don't know why we put in so much time educating these parents, they don't seem to care what we say." Which is the best response to the UAP about the importance of educating parents of children with ASD?

"We help parents feel relieved to have specific strategies that can help them and their child be more successful." Explanation: Parents feel empowered and relieved to have specific strategies that can help them and their child be more successful. Including parents in planning and providing care for the child with ADHD is important. Telling the UAP that the parents are too overwhelmed to hear supports the negativity of the UAP's statement. Education is a priority and is not only given because the parents are paying for the child's care. There is not an obligation because a child receives special services that the parents are required to be educated, but it is an expectation.

After educating the parents of a child diagnosed with attention deficit hyperactivity disorder (ADHD) on the disorder and its treatment, the nurse determines that the education has been effective when the parents make which statement?

"We need to remember that our child is not a bad kid but just has difficulty with impulse control and attention." Explanation: Educating clients and families on the biological basis of ADHD helps parents understand that these children are not "bad" kids but that they have problems with impulse control and attention. It may be helpful to review the purposes of the medications and assure the parents that there is evidence that medications help most children. Studies show that treatment of ADHD is not associated with a risk of substance disorders. The health care provider, not the parents, would determine when it would be appropriate to take a drug holiday to evaluate the need for continued medication therapy. Regular routines are important, but so are clear limits with clear consequences when these limits are violated.

The nurse is educating parents of a child with attention-deficit/hyperactivity disorder (ADHD). Which statement by the parents would indicate the need for further teaching?

"We'll have the child do homework at the kitchen table with the child's siblings." Explanation: The child with ADHD cannot accomplish complex tasks, such as homework, in a noisy or chaotic setting where there are a lot of distractions. The other choices do not indicate the need for further teaching.

A client with bipolar disorder states to the nurse that they have been experiencing mania and depression every day for 2 weeks and cannot work or take care of their children. Which is the bestresponse by the nurse?

"You are rapid-cycling and we may need to make an adjustment with your medication." Explanation: A mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week. These mixed episodes are often called rapid cycling. The medication regimen may need to be altered to control these symptoms. These symptoms are not typical with all clients with bipolar disorder. The nurse should not respond in an accusatory manner with questioning the client about not taking medication. This can occur even when a client takes their medication as prescribed. The client does not meet the criteria for involuntary admission and may be managed in an outpatient setting.

A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what?

1.0 mEq/L Explanation: Serum plasma lithium levels should range from 0.6 to 1.2 mEq/L. Levels above that suggest toxicity (moderate toxicity for levels 1.5 to 2.5 mEq/L; severe toxicity for levels greater than 2.5 mEq/L).

A patient with bipolar I disorder being treated with lithium is brought to the emergency department. Assessment reveals moderate ataxia, slurred speech, asymmetric deep tendon reflexes, muscle twitching and increased muscle tone. The nurse suspects moderate lithium toxicity. Which lithium blood level would support the nurse's suspicion?

2.2 mEq/L Explanation: Lithium levels between 1.5 to 2.5 mEq/L indicate moderate toxicity as evidenced by the client's symptoms. Levels below 1.5 mEq/L suggest mild side effects. Levels greater than 2.5 mEq/L indicate severe toxicity, which can lead to coma and death.

Assessment of an 8-year-old client reveals communication difficulties and an inability to manage age-appropriate tasks. The child undergoes standardized testing. An intelligent quotient (IQ) of which would support a diagnosis of intellectual disability?

65 Explanation: The usual threshold for intellectual disability is an IQ of 70 or less (i.e., two standard deviations below the population mean).

When describing intellectual disability to a group of parents, a nurse would identify which intelligent quotient (or less) as the usual threshold?

70 Explanation: The usual threshold for intellectual disability is an intelligence quotient of 70 or less (i.e., two standard deviations below the population mean).

Which sleep pattern is suggestive of a manic episode?

A client stays awake for several days and nights before "crashing" and sleeping for a long period. Explanation: During a manic episode, an individual will typically go several nights without sleep before collapsing from exhaustion.

A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client?

Ability to concentrate and process the information Explanation: To best assure successful outcomes related to client education of an individual experiencing a manic episode, the nurse's initial assessment is focused on the client's ability to concentrate and process the information.

A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?

Accompany the client to their room to get dressed. Explanation: Redirecting the client to appropriate behavior without confrontation is most effective. Seclusion is not an appropriate intervention for this situation. Ignoring the behavior is not indicated. The client is in the manic phase; telling them to stop the behavior may make the behaviors escalate.

The nurse is assessing the adaptive functioning skills of a child diagnosed with intellectual disability. Which of the following would the nurse assess?

Activities of daily living Communication skills Academic skills Safety concerns Explanation: The essential feature of intellectual disability is below-average intellectual functioning (intelligence quotient [IQ] less than 70) accompanied by significant limitations in areas of adaptive functioning such as communication skills, self-care, home living, social or interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, and health and safety. Spiritually is not an assessable characteristic in this case

The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what?

An elevated mood that lasts for at least 1 week Explanation: During manic episodes that characterize bipolar disorder, the individual exhibits an abnormal, persistently elevated, or irritable mood that lasts for at least 1 week. Failure to respond to treatment, the presence of signs of depression without anhedonia, and the client's admission of a mood disorder are neither diagnostic nor typical of bipolar disorder.

A nurse is reviewing information about medications used to treat bipolar disorders. The nurse demonstrates understanding by identifying which medication classification as effective in stabilizing moods in people with bipolar disorder?

Anticonvulsants Explanation: Several anticonvulsants traditionally used to treat seizure disorders have proved helpful in stabilizing the moods of people with bipolar illness.

A client has just been diagnosed as having major depression. At which time would the nurse assess the client to be at highest risk for self-harm?

Approximately 2 weeks after starting antidepressant medication Explanation: Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide.

Which is a food that might be incorporated into the plan of care for a client diagnosed in the manic phase of bipolar disorder?

Bananas Explanation: For a client who is unable to sit long enough to eat, snacks and high-energy foods that can be eaten while moving should be provided.

A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile?

Bipolar I Explanation: Bipolar I disorder is characterized by one or more manic episodes, usually alternating with major depressive episodes.

When teaching a client who is recently diagnosed bipolar I disorder, the nurse correctly tells the client that the difference between bipolar I disorder and bipolar II disorder is what?

Bipolar I disorder is often more disruptive than bipolar II disorder. Explanation: Bipolar I disorder is often more severe, thus symptoms tend to create more disruption in functioning compared to bipolar II disorder. Bipolar I disorder is characterized by one or more manic or mixed episodes in which the individual experiences rapidly alternating moods accompanied by symptoms of a manic mood and a major depressive episode.

A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications?

Carbamazepine Explanation: Carbamazepine is an anticonvulsant with mood-stabilizing effects. Lithium is a mood stabilizer. Mannitol and methyldopa are not used in the treatment of bipolar disorder.

A nurse is evaluating a child's attention span. Which finding indicates that the child's attention span is decreased?

Child is rocking in the chair continuously. Explanation: Indications of decreased attention span include hyperactivity, inability to stay focused during an interview/conversation, and inability to perform simple tasks. The ability to count backwards, read a book, and be engaged in a conversation indicates an adequate attention span.

A preadolescent client has been considered a neighborhood bully for several years. Peers avoid them, and the parent says, "I cannot believe a thing my child tells me." Recently, the client was observed shooting at several dogs with a pellet gun and setting fire to a vacant lot for the first time. A nurse would assess these behaviors as being most consistent with which disorder?

Conduct disorder Explanation: Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. These clients have significantly impaired abilities to function in social, academic, or occupational areas. Symptoms are clustered in four areas: aggression to people and animals, destruction of property, deceitfulness and theft, and serious violation of rules. This is an example of moderate conduct. Moderate: The number of conduct problems increases as does the amount of harm to others. Examples include vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity. Oppositional defiant disorder consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations. The behaviors are more pervasive than defiance of authority. To suffer from pyromania is more than one incidence of setting a fire.

After being arrested for prostitution, an adolescent client has been referred to a mental health clinic by a juvenile officer. The client has a history of truancy and being physically abusive to siblings. From the history gathered during assessment, the nurse identifies that these behaviors correlate with which disorder?

Conduct disorder Explanation: Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. These clients have significantly impaired abilities to function in social, academic, or occupational areas. Symptoms are clustered in four areas: aggression to people and animals, destruction of property, deceitfulness and theft, and serious violation of rules. This is an example of moderate conduct. Moderate: The number of conduct problems increases, as does the amount of harm to others. Examples include vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity. Oppositional defiant disorder consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations. Intermittent explosive disorder involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes. Many children can experience depression with social isolation, but in this case, it is a symptom and not a diagnosis.

The nurse is providing client education to an individual who has recently been diagnosed with bipolar disorder and is starting divalproex sodium therapy. What priority information should the nurse include in the plan of care?

Confirm baseline labs have been ordered prior to starting therapy. Explanation: Prior to the initiation of divalproex sodium therapy, baseline CBC with differential and liver function tests should be taken. Because this medication can lead to hepatotoxicity, it is important to both establish a baseline and continue to monitor on a weekly basis to verify therapeutic levels. Finding out the name of the client's pharmacy may be needed to fill the prescription. Weight gain is an associated side effect of therapy, not weight loss.

A nurse working with an adolescent client diagnosed with disruptive behavior disorder is developing a plan of care to improve outcomes. Which nursing action best supports the use of problem-solving therapy?

Consider alternative approaches based on their individual merits. Explanation: Problem-solving therapy focuses on the development of alternatives to respond to situations looking at the presented facts, thinking about consequences, and evaluating responses to decision-making. Providing a checklist does not fully address all key elements of problem-solving. Telling the client that one should wait 24 hours before making any choice may not be appropriate. Although it is important to focus on understanding of words and their meanings, that by itself is not the best approach to problem-solving.

A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention will be performed first?

Decrease the client's environmental stimuli. Explanation: When the client is agitated, decreasing stimuli is the priority because it is likely to reduce the client's agitation. Giving an agitated client feedback about their behavior may provoke confrontation. Similarly, making reference to rules and policies may make the client reactive or defensive, exacerbating the situation. Introducing the client to other staff does nothing to address the client's agitation.

Which is an anticonvulsant used as a mood stabilizer?

Divalproex Explanation: Divalproex is an anticonvulsant that may be used as a mood stabilizer. Venlafaxine, bupropion, and phenelzine are antidepressants.

A 35-year-old client with bipolar disorder has a history of discontinuing medication when feeling well and then becoming manic again. During the client's last episode of mania, the client lost several thousand dollars in risky investments. Which intervention will be most helpful in achieving medication adherence?

During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse. Explanation: To help link the importance of taking medication with relapse prevention, the nurse lists target symptoms and identifies signs of imminent relapse. The nurse engages in problem solving with the client about early management of symptoms so severity does not increase.

A child is diagnosed with encopresis. Which of the following would be most important for the nurse to do first?

Educate the parents and child about normal bowel function. Explanation: Effective intervention begins with educating the parents and the child about normal bowel function, as well as the self-perpetuating cycle of fecal impaction and leakage of stool around the hardened mass of feces. The short-term goal of this educational effort is to decrease the anger and recrimination that often complicate the picture in these families. Because encopresis often results in a loss of bowel tone, it may help to motivate children by emphasizing the need to strengthen their muscles. In many cases, cleaning out the bowel is necessary before initiating behavioral treatment. Bowel catharsis is usually followed by administration of mineral oil, which is often continued during the bowel retraining program. A high-fiber diet is often recommended.

A client with a diagnosis of bipolar disorder is described by a family member as "flip-flopping between being happy and loving to irritable and hostile." Which characteristic symptoms of this disorder is the family member referring to?

Emotional lability Explanation: Emotional lability is alterations in moods with little or no change in external events. It is a term used for the rapid shifts in moods that often occur in bipolar disorder.

A nursing student learning about mood disorders correctly identifies which of the following to mean exaggerated feelings of well-being?

Euphoria Explanation: An elevated mood can be expressed as euphoria, which is exaggerated feelings of well-being or elation. Examples include feeling high, ecstatic, and on top of the world. An expansive mood is characterized by lack of restraint in expressive feelings. Paranoia is rooted in suspicions about others, or delusions of persecution. For some, an irritable mood is feeling easily annoyed and provoked to anger, especially when their wishes are challenged or thwarted.

When developing the plan of care for the family of a child with a neurodevelopmental disorder, which of the following would be least appropriate to include?

Excluding the parents from being included in the plan of care Explanation: Useful nursing interventions focusing on the family include: interpreting the treatment plan for parents and child; modeling appropriate behavior modification techniques; including the parents as cotherapists for the implementation of the care plan; assisting the family in identifying and resolving their sense of loss related to the diagnosis; coordinating support systems for parents, siblings, and family members; and maintaining interdisciplinary collaboration.

A client has been on lithium for 3 weeks now. The client approaches the nurse, saying, "I feel like I'm going to throw up, and I can't even hold this cup of coffee straight. Why can't I do the crossword puzzle? I usually can do them in about 5 minutes." What is the appropriate nursing intervention at this time?

Further assess the client's symptoms, call the physician, hold the client's next dose of lithium, and have a blood level drawn because the client is showing symptoms of toxicity. Explanation: Lithium has a fairly narrow therapeutic window. The client is experiencing adverse effects and should receive no additional dose until a lithium blood level is drawn and the physician is contacted. Symptoms at a serum lithium level of 1.5 mEq/L are nausea and vomiting, fine hand tremors, and lethargy.

After teaching a group of nursing students about intellectual disability, the instructor determines that the teaching was successful when the students identify which as the most common etiology?

Genetic syndromes Explanation: Although exposure to toxins, perinatal complications, and environmental effects are associated with intellectual disability, the most common etiology is related to genetic syndromes.

The parents of a child diagnosed with ADHD ask the nurse about the restricted elimination diet. When describing this diet, which food would the nurse include as being allowed?

Gluten-free grains Fish Nuts Explanation: The restricted elimination diet has been shown to improve behavior in some children and can be used as an instrument to determine whether ADHD behaviors are induced by food. In this diet, all-natural, chemical-free foods are eaten, and most of the foods that are regularly eaten are removed. Fruits, vegetables, nuts, nut butters, beans, seeds, gluten-free grains (e.g., rice, quinoa), fish, lamb, wild game meats, organic turkey, and large amounts of water are consumed.

A client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what?

Grandiosity Explanation: Grandiosity is elevated self-esteem and may range from unusual self-confidence to grandiose delusions. Speech is pressured; the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas or racing thoughts.

Which intervention assists the nurse to gain rapport with the child and parent?

Greet the child in friendly, personal way. Explanation: The assessment interview is the initial contact between the child and parent or caregiver and the nurse. The first step is to establish rapport by greeting the child or adolescent in a friendly, polite, open manner and putting him or her at ease.

A client who has liver damage is receiving lithium for treatment of bipolar disorder. The nurse understands that which of the following may occur when the client is receiving lithium?

Increased plasma concentration Explanation: Hepatic and renal impairments increase plasma concentration of lithium.

A nurse is conducting a presentation about autism spectrum disorder for a group of parents. When describing this condition, the nurse would identify that approximately 50% of those with this condition also experience which of the following?

Intellectual disability Explanation: About half of children with autism spectrum disorder have intellectual disability, and about 25% have seizure disorders. Hypertension and motor decline are not associated with autism.

A nurse is reviewing information about disruptive behavior disorders in children. Which finding best describes this clinical diagnosis?

It can lead to increased risk of other mental health disorders. Explanation: Disruptive behavior disorders occur more in males than females. Females who have been diagnosed with disruptive behavior disorder display more sexual behaviors than males. Males display physical as well as relational aggression, whereas females tend to display relational aggression. Individuals who are diagnosed with this type of disorder are more likely to have other mental health disorders, such as anxiety, mood disorders, and/or substance use disorders.

After educating a group of students on attention deficit hyperactivity disorder (ADHD), the instructor determines that additional education is required when the group identifies which as a typical characteristic?

Language difficulty Explanation: A persistent pattern of inattention, hyperactivity, and impulsiveness that interferes with functioning characterizes ADHD. Language difficulties are not associated with ADHD.

A psychiatric-mental health nurse is preparing a review class for a group of nurses at the community mental health center. The topic is mood-stabilizing drugs. After teaching the class about the different drugs that may be prescribed, the nurse determines that the teaching was successful when the group identifies which drug as being prescribed most often?

Lithium Explanation: The mainstays of pharmacotherapy are the mood-stabilizing drugs, including lithium carbonate (Lithium), divalproex sodium (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal). Of these, lithium is the most widely used mood stabilizer.

A nurse is developing a plan of care for a client with bipolar disorder. When preparing to administer medications, which agent would the nurse anticipate as being prescribed as the mainstay of pharmacotherapy?

Lithium carbonate Divalproex Carbamazepine Lamotrigine Explanation: The mainstays of pharmacotherapy for bipolar disorder are mood-stabilizing drugs, including lithium, divalproex, carbamazepine, and lamotrigine. Antidepressants, such as fluoxetine, are not recommended in those with bipolar depression because of a risk of switching to mania.

A client is prescribed lithium to treat mania. The client also has a history of hypertension for which the client takes lisinopril and hydrocholorothiazide. When monitoring this client, the nurse would be especially alert for signs and symptoms of which condition?

Lithium toxicity Explanation: Lisinopril is an ACE inhibitor; hydrochlorothiazide is a thiazide diuretic. Both drugs interact with lithium to increase serum lithium levels. Therefore, the nurse should be especially alert for signs and symptoms of lithium toxicity. Hypokalemia and hyponatremia are possible effects of hydrochlorothiazide when given alone but these wouldn't be as great a concern as the increased risk for lithium toxicity. Hypertensive crisis would be more commonly associated with the use of MAOIs and tyramine foods.

A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy?

Liver function Explanation: Baseline liver function tests and a complete blood count with platelets should be obtained before starting therapy, and clients with known liver disease should not be given divalproex sodium. There is a boxed warning for hepatotoxicity. Thyroid level, WBC count, and cardiac enzymes do not have to be performed routinely before starting this medication.

A patient with bipolar disorder is prescribed divalproex. Before initiating this therapy, which laboratory test would be most important for the nurse to obtain?

Liver function tests Explanation: For clients who are prescribed divalproex, baseline liver function tests and a complete blood count with platelets should be obtained before starting therapy because of the increased risk for hepatotoxicity. Clotting function tests, renal function tests, and blood glucose level are not needed prior to initiating therapy.

A client taking lithium therapy has a serum therapeutic level of 0.8 mEq/L. What priority dietary instruction should the nurse include in the teaching plan?

Maintain daily sodium intake. Explanation: Consistent sodium intake is critical with lithium therapy. A serum therapeutic level of 0.8mEq/L is within the therapeutic range of 0.6-1.2 mEq/L. Fluid intake on lithium therapy should be increased to 2 L/day. Switching to a DASH diet is used to treat HTN. Monitoring weight pattern should be included but it is not the current priority.

A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what?

Mania Explanation: Physical appearance is a factor that influences communication; the client with mania may dress in brightly colored clothes with several items of jewelry and excessive makeup.

A client with bipolar disorder takes lithium 300 mg 3 times daily. The nurse is educating the client on its use, side effects, and need for compliance. Which outcome does the nurse evaluate that indicates the dose is having the beneficial response for the client?

Minimal mood swings Explanation: Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Weight gain is a common side effect, and fatigue and lethargy may indicate mild toxicity. Inflated self-worth is a target symptom of bipolar disorder, which should diminish with effective treatment.

A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention?

Monitoring blood levels of the medication. Explanation: Lithium is the drug of choice for clients with bipolar illness and has a high antimanic effectiveness. Lithium decreases the intensity, frequency, and duration of manic and depressive episodes. Blood levels need to be monitored for therapeutic levels during the acute phase (1.0-1.5 mEq/L) and during longer term maintenance. Other treatments that could be expected for clients during mania include sedatives or antipsychotics. Electroconvulsive therapy, phototherapy, and monoamine oxidase inhibitors are not typically indicated during manic phases.

A client is exhibiting rapid shifts in mood. The nurse documents this as which of the following?

Mood lability Explanation: Mood lability is a term used for rapid shifts in mood that often occur with bipolar disorder. Elevated mood refers to exaggerated feelings of well-being (euphoria) or feeling ecstatic or high (elation). An expansive mood is characterized by lack of restraint in expressing feelings, an overvalued sense of self-importance, and a constant and indiscriminate enthusiasm for interpersonal, sexual or occupational interactions. An irritable mood is indicated by being easily annoyed and provoked to anger, especially when wishes are challenged or thwarted.

Which medication classification is considered first-line drug therapy for bipolar disorder?

Mood stabilizers Explanation: Mood stabilizers are first-line drugs for bipolar disorders. They stabilize depressive and manic cycles.

Which of the following is an adverse effect of lithium?

Nausea and diarrhea

A client with bipolar disorder has been taking lithium, and today the client's serum lithium level is 2.0 mEq/L (2.0 mmol/L). What effects would the nurse expect to see?

Nausea, diarrhea, and confusion Explanation: Serum lithium levels of less than 0.5 mEq/L (0.5 mmol/L) are rarely therapeutic, and levels of more than 1.5 mEq/L (1.5 mmol/L) are usually considered toxic. The client would show signs of toxicity with a lithium level of 2.0 mEq/L (2.0 mmol/L). Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination.

Both valproate and carbamazepine may be lethal if high doses are ingested. Toxic symptoms appear in 1 to 3 hours and include what?

Neuromuscular disturbances Explanation: Symptoms include neuromuscular disturbances, dizziness, stupor, agitation, disorientation, nystagmus, urinary retention, nausea and vomiting, tachycardia, hypotension or hypertension, cardiovascular shock, coma, and respiratory depression. Tinnitus does not occur with lethal doses of these drugs.

After teaching a group of students about medications used to treat ADHD, the instructor determines that the education was successful when the group identifies atomoxetine as which of the following?

Noradrenergic reuptake inhibitor Explanation: Atomoxetine (Strattera), a noradrenergic reuptake inhibitor, is not classified as a stimulant and is effective in the treatment of ADHD. Antipsychotics are rarely used to treat ADHD. Methylphenidate is a stimulant. Alpha agonists include guanfacine and clonidine.

A nurse who works primarily with clients who have bipolar disorder identifies which group of clients as not being candidates to take lithium as treatment?

Patients who take ACE inhibitors Explanation: Lithium interacts with several different medications and foods. Clients who take ACE inhibitors should not take lithium, because the combination can increase the serum lithium level, leading to toxicity and impaired kidney function.

Which of the following disorders involves problems with forming sounds associated with speech?

Phonologic disorder Explanation: Phonologic disorder involves problems with articulation. Mixed receptive-expressive language disorder includes problems of expressive language disorder along with difficulty understanding and determining the meaning of words and sentences. Expressive language disorder involves an impaired ability to communicate through verbal and sign language. Stuttering is a disturbance of the normal fluency and time patterning of speech.

A client was admitted to the psychiatric unit after being picked up by police officers who found the client frantically running back and forth across the freeway. The client's spouse reports that the client stayed up all night, ate very little, and talked incessantly. Additional assessment findings that indicate a manic episode include what?

Pressured speech, combative behavior, and impaired judgment Explanation: A manic episode would be characterized by pressured speech, potentially combative behavior, and impaired judgment. Neither psychomotor retardation is present nor are recurrent illusions. Self-destructive behavior is not a classic symptom of mania; more often, clients may have accidents caused by their lack of judgment and psychomotor agitation.

Which of the following approaches is included in milieu management for the child with autism spectrum disorder?

Providing a structured, routine environment Explanation: Milieu management—a consistent, structured environment with predictable routines for activities, mealtimes, and bedtimes—is necessary for successful treatment. Changes in routine may provoke disorganization in the child, leading to emotional disequilibrium and explosive behavior. Children with autism spectrum disorder often have social deficits, therefore a group talk or activites that promote interpersonal interaction would be inappropriate. Climbing structures and rolling chairs would be problematic and impose a safety risk. Listening to the parents feelings and frustrations would fall in the psychosocial domain of treatment for a child with ASD.

A client with bipolar disorder is experiencing acute mania. The client is unable to sit still, moving from place to place. Medication therapy has been prescribed but not yet initiated. Which would the nurse include in the plan of care to meet the client's physical needs?

Providing high energy snacks Explanation: For the client experiencing acute mania, the nurse would provide snacks and high energy foods because it is highly likely that the client is unable to sit long enough to eat. Sleep hygiene is a priority but may not be realistic until medications take effect. Because of the client's activity level, frequent rest periods would be unlikely. Limiting stimuli would be helpful in decreasing agitation.

An 8-year-old boy has been diagnosed with ADHD. His mother is shocked that he will be prescribed a psychostimulant, stating, "His whole problem is that he's too stimulated, not understimulated!" Which of the following facts should underlie the nurse's response to the mother?

Psychostimulants stimulate the areas of the brain that control attention, impulses, and self-regulation of behavior. Explanation: Psychostimulants stimulate the areas of the brain that control attention, impulses, and self-regulation of behavior, with the resulting effect of improved self-control.

The nurse is working with clients who have disruptive behavior disorders. Which are important point(s) for the nurse to consider when working with these clients and their families?

Remember to focus on the client's strengths and assets, as well as their problems. Avoid a "blaming" attitude toward clients and/or families. Focus on positive actions to improve situations and/or behaviors. Explanation: Points to consider when working with clients with disruptive behavior disorders and their families include remembering to focus on the client's strengths and assets, as well as their problems, and avoiding a blaming attitude toward clients and/or families. The nurse should focus on positive actions to improve situations and/or behaviors. There is a familial tendency for behavior disorders, but that is not the only cause for behavior disorders and so the nurse cannot assume that the client's parents also had a conduct disorder. Conduct disorders are not common in all children, but it can be difficult to distinguish normal child behavior from conduct disorders at times.

Assessment of a child with autism spectrum disorder reveals stereotypic behavior. Which behavior would the nurse most likely document being demonstrated by the child?

Rocking Hand flapping Head banging Explanation: Stereotypic behavior incudes self-stimulating, nonfunctional, repetitive behaviors such as rocking, hand flapping, and head banging. Word repetition (echolalia) and pronoun reversal are communication difficulties.

The nurse is reviewing the history of a client diagnosed with bipolar I disorder. The history reveals that the client, in between manic episodes, consistently uses self-negating statements when describing the self, expresses feelings of being ashamed, and describes self as being unable to deal with events. The client also demonstrates little to any eye contact during interactions. The nurse interprets this information as reflecting a problem in which area?

Self-esteem Explanation: These characteristics reflect issues related to self-esteem, or more specifically low self-esteem. The findings are unrelated to anxiety, coping, or denial.

A nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what?

Self-injury Explanation: During a manic episode, client safety is a priority. Risk of suicide is always present for those having a depressive or manic episode. During a depressive episode, the client may believe that life is not worth living. During a manic episode, the client may believe that he or she has supernatural powers, such as the ability to fly. Although changes in sleep, fluid balance (such as dehydration), and inadequate nutrition manifested by weight loss would be important to assess, safety and prevention of self-injury are the priority.

A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. Which is the priority action by the nurse?

Set and maintain limitations on behavior to avoid threat to others' rights. Explanation: The nurse must set limits on this intrusive behavior because other clients have the right to be protected. The client is in the manic phase; and may not be aware that the behavior they are exhibiting is inappropriate. The behavior could be an imminent threat to individual safety for many reasons, infection control included. The client's need for food and fluids does not supersede any of the other clients' needs for food and fluids. The client should not be threatened with isolation during mealtimes and finger foods may be provided so that the client is not tempted to take food off of others trays. The client should not be removed from the lunchroom, but allowed to stay with firm limitations on behavior.

When assisting the parents of a child diagnosed with ADHD, which of the following would the nurse suggest?

Set clear limits with consequences Keep to regular routines Maintain a calm environment Explanation: Interventions that can help the parents of a child with ADHD include: setting clear limits with clear consequences, using few words and simplifying instructions; establishing and maintaining a predictable environment with clear rules and regular routines for eating, sleeping, and playing; promoting attention by maintaining a calm environment with few stimuli; establishing eye contact before giving directions and asking the child to repeat what was heard; encouraging the child to do homework in a quiet place outside of a traffic pattern; and assisting the child to work on one assignment at a time (reward with a break after each completion).

Administration of lithium affects which of the following electrolytes?

Sodium Explanation: Clients should drink adequate water and continue with the usual amount of dietary salt. Having too much salt in the diet because of unusually salty foods or the ingestion of salt-containing antacids can reduce receptor availability for lithium and increase lithium excretion, so that the lithium level is too low to be therapeutic.

A nurse is assessing a client who is brought to the emergency department. The nurse suspects that the client is experiencing mania. Which finding would support the nurse's suspicion?

Statements of self-importance Flight of ideas Easily distractible Explanation: Mania is one of the primary symptoms of bipolar disorders. It is evidenced by an elevated, expansive, or irritable mood. Elevated self-esteem is expressed as grandiosity (exaggerating personal importance) and may range from unusual self-confidence to grandiose delusions. Speech is pressured (push of speech) the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas (illogical connections between thoughts) or racing thoughts. Distractibility increases.

A nurse is reviewing information about the drug, lithium carbonate. The nurse demonstrates understanding of the information by identifying which situation as a potential cause of lithium toxicity?

Strenuous exercise Diarrhea Hot climate Vomiting Explanation: If body fluid decreases significantly because of a hot climate, strenuous exercise, vomiting, diarrhea, or a drastic reduction in fluid intake, then lithium concentrations can rise sharply, causing an increase in side effects and a progression to lethal lithium toxicity. The higher the sodium concentrations, the lower the lithium concentrations will be.

To confirm that a client is experiencing a manic episode, the nurse must eliminate the possibility that the client's symptoms are related to which problem?

Substance use Explanation: The effects of illicit substance use can mimic the symptoms of mania. The use of substances must be ruled out through the use of blood and urine diagnostics. Once determined that the signs and symptoms are not the result of substances, the client can be further investigated for mania.

A 7-year-old client experiences tics, which have become increasingly frequent in recent months. How should the nurse educate the client's teacher to respond to the tics?

Teach the client's classmates that the tics are not something that the client can control. Explanation: Tics are largely involuntary, especially in younger children. Establishing a pattern of rewards or consequences would be ineffective and inappropriate. A calm environment may be of some benefit, but the priority would be teaching others that the client's behavior is not deliberate.

The nurse is talking with the parents of a child with disruptive behavior disorder about ways to help the child manage behaviors. Which action is best for the nurse advocate for the child to have their needs met?

Teach the parents age-appropriate expectations of the child. Explanation: Working with parents is a crucial aspect of dealing with children with these disruptive behavior disorders. The nurse can teach parents age-appropriate activities and expectations for clients and consequently increase the child's chance of meeting expectations for behavior. Transferring the child to a new home would be a measure of last resort with the goal of protecting the child's safety. The nurse should avoiding appearing to "side" with the parents in an effort to advocate for the child and maintain a therapeutic relationship. It is presumptuous for the nurse to believe they know the child's thoughts and feelings best and has to interpret them to the parents.

A nurse is working with a child who is experiencing separation anxiety. Which behavior(s) will support this diagnosis?

The child talks of a recent death in the family. The child attempts to block the door from parent leaving. The child appears to lack focus. The child shows great worry when separated from parent. Explanation: Separation anxiety is normal for very young children, but typically declines between ages 3 and 5 years. Separation anxiety disorder is the most common childhood anxiety disorder. Although many children experience some discomfort on separation from their attachment figures, children with separation anxiety disorder suffer great worry or fear when faced with ordinary separations from parents or being away from home. They often display lack of focus to participate in any setting when they are separated from their caregiver. In some instances, the family may be undergoing a separation of a significant family member through death, divorce, or military deployment. In other situations, the arrival of a new family member (birth or marriage is an example) may precede the child's separation anxiety. When asked, most children with separation anxiety disorder will express worry about harm to or permanent loss of their major attachment figure. Some will attempt to keep the parent from leaving them as seen in the child blocking the door. Often they will cling to the parent and not turn them loose. Other children may express worry about their own safety. The family dynamics related to the child's behavior have to be carefully assessed. The child being timid, fearful and trying to hide may be indicative of abuse. Hiding is not normally seen with separation anxiety.

The nurse is documenting clinical observations after a therapeutic session with an adolescent client with a disruptive behavior disorder. What should the nurse identify is an internalizing behavior?

The client only stares at the nurse when asked how the client is doing today. Explanation: An example of an internalizing behavior that can be observed in clients with disruptive behavior disorders is refraining from talking. The client who just stares at the nurse when asked a question is demonstrating internalizing behaviors common in disruptive behavior disorders. Not showing up for multiple appointments is an example of truancy, an externalizing behavior common in disruptive behavior disorders. Telling the nurse that her grandmother passed away when, in fact, this is not true, indicates that the client is lying. Lying is one example of an externalizing behavior in disruptive behavior disorders. Pushing a chair over during the therapeutic session is an example of an angry outburst with aggression. This is an externalizing behavior.

The client is 6-year-old who has been diagnosed with autism spectrum disorder. Which symptom would the client display?

The client spends time alone with little interest in making friends. Explanation: Children with autism spectrum disorder develop language slowly or not at all. They may use words without attaching meaning to them or communicate with only gestures or noises. They spend time alone and show little interest in making friends. Autism spectrum disorder is not associated with over attachment, pulling out hair, or tics.

A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which goal would be most appropriate for this client?

The client will refrain from being intrusive with others and change clothing only twice per day. Explanation: The focus should be on symptom management and containment until the client recovers enough to participate in more structured nursing interventions. Small limitations relative to hugging and wardrobe changes are realistic, offer a measure of change/stability, and help decrease overall hypomanic behaviors. Recording the number of clothing changes per day is not realistic. Having staff members of the opposite sex help the client choose appropriate dress is incorrect because this behavior will encourage continued inappropriate sexual advances. The client does not have difficulties with low self-esteem.

A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching?

The higher the sodium level, the lower the lithium level will be. Explanation: Lithium is a salt, so the interaction between lithium and sodium levels in the body and between lithium level and fluid volume in the body are crucial issues to consider. The higher the sodium levels, the lower the lithium level will be and vice versa. The other options do not represent correct information.

The parent of a 6-year-old child with autism spectrum disorder (ASD) informs the nurse that the temper tantrums are getting difficult to control and the parent is afraid of what the child will do to themself and other family members. Which option will the nurse discuss with the parent to help manage the behaviors?

The use of antipsychotic medications may be helpful with the tantrums and aggression. Explanation: Pharmacologic treatment with antipsychotics, such as haloperidol, risperidone, aripiprazole, or combination of antipsychotic medications, may be effective for specific target symptoms, such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors. The behaviors are not a result of lack of discipline, so a firmer approach will not be effective. The behaviors may not necessarily improve as the child ages but may be able to be managed with medications and therapy. Inpatient care is not a requirement for treatment and may not be a viable option for parents with such a young child.

A nurse is reviewing information about Tourette's disorder in preparation for a presentation about the condition. The nurse demonstrates understanding of the information by identifying which information as most accurate?

There are no diagnostic tests used for this disorder. Explanation: Because there are no diagnostic tests used for this disorder, the diagnosis is based on the type and duration of tics present. The child can suppress the tics for brief periods. It is common to hear from parents that their child has more frequent tics at home than at school. The general trend is for tic symptoms to decline by early adulthood.

Which of the following conditions is characterized by multiple motor tics and one or more vocal tics many times throughout the day for 1 year or more?

Tourette's syndrome Explanation: Tourette's disorder, the most severe tic disorder, is defined by multiple motor and phonic tics for at least one year. Tics are not associated with autism spectrum disorder, attention deficit hyperactivity disorder or intellectual disability.

The nurse is caring for a client that is experiencing mania that is pacing, cannot sit, with pressured speech. Which meal will the nurse provide to best meet the nutritional needs of this client?

Turkey sandwich, cheese slices, milk Explanation: Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. Sandwiches and cheese are finger foods and are calorie-dense. Chips and cola are not nutritious, even though they are high in calories. Fried chicken, potatoes, and spaghetti cannot be eaten while the client is moving.

A client with acute mania is prescribed lithium. During this time, the nurse would anticipate obtaining blood concentrations how often?

Twice weekly Explanation: In acute mania, it is important for the client to obtain serum concentrations twice weekly in the acute phase. In uncomplicated maintenance, serum concentrations should be obtained every 2 to 3 months.

A client taking lithium for bipolar disorder comes to the clinic and reports symptoms which the nurse interprets as consistent with moderate lithium toxicity. Which action should the nurse perform?

Withhold additional doses of lithium. Obtain a blood sample for lithium level. Push fluids. Contact the physician. Explanation: If symptoms of moderate to severe toxicity to lithium are noted, the nurse should withhold the medication, obtain a blood sample to analyze the lithium level, push fluids, and contact the physician for further instructions.

A client tells the nurse that their significant other acts using non-supportive behavior, which is the same way that their parent, who also had a mental health issue, acted. How would the nurse bestcategorize this relationship?

assortative mating Explanation: Assortative mating is where one secures a relationship with someone who has similar characteristics to a family member who has a mental health trait/disorder. Genetic research has shown a vulnerability between nurture and nature whereby individuals look to maintain a consistent behavioral relationship. As the client indicates that there is non-supportive behavior, there is no way to assess that this is a realistic, potentially insignificant and/or mutually beneficial relationship.

A nurse is assessing a 10-year-old child who is displaying behaviors that are consistent with oppositional defiance disorder. When conducting the assessment, the nurse should also assess for which co-morbidity?

attention deficit hyperactivity disorder Explanation: Oppositional defiance disorder is often co-morbid with other psychiatric disorders that need to be treated as well. It is possible that the oppositional defiance disorder is superimposed on the attention deficit hyperactivity disorder because this problem is the underlying cause of the child's maladaptive behaviors.

A child with attention deficit hyperactivity disorder is taking methylphenidate in divided doses. If the child takes the first dose at 0800. Which behavior might the school nurse expect to see at noon?

increased impulsivity or hyperactive behavior Explanation: Ritalin has a short half-life, so doses are needed about every 4 hours during the day to maintain symptom control. The child's symptoms may worsen four hours after a dose. Giving stimulants during daytime hours usually effectively combats insomnia. Social isolation is likely to be an ongoing, long term problem that is unrelated to the precise timing of doses. A loss of appetite is more likely when serum levels of the drug are higher.

Which are included in the mental health comprehensive evaluation of children and adolescents?

medical history mental status examination school records Explanation: A comprehensive evaluation includes a history, mental status examination, records of the child's school performance and medical-physical history, screening tools, and information from other agencies.

A nurse is working with a pediatric client who appears shy but then warms up to the interaction and becomes engaged. How would the nurse best describe the client's temperament?

slow-to-warm-up and appropriate Explanation: A slow-to-warm-up temperament is characterized by a negative response that changes to a positive response over time. Temperaments are categorized as easy, difficult, and slow-to-warm-up. They can be construed as being positive or negative. There is no provided information relative to age and/or developmental delay, so the nurse cannot make that judgment.