Mental Health Nur 220 "Quiz"

The client with chronic anxiety is being discharged. Which of the following should the nurse include in the discharge plan? A. Contact crisis counselor once a week B. identify anxiety-producing situations C. try to repress feelings of anxiety D. eliminate stress and anxiety from daily life

B. identify anxiety-producing situations

ATI: A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5mL. How many mL should the nurse administer

14 mL

ATI: A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is a diazepam injection 5mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

1.5 mL

ATI: A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? A. Arrange one-to-one observation of the client. B. Encourage interaction with the client's peers. C. Administer medication for depressive disorder. D. Encourage the client to attend a support group.

A. Arrange one-to-one observation of the client. The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety.

ATI: A nurse is assessing a client who has a terminal illness and adjusts to a progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? A. "I am going to order a wheelchair for when I'm unable to walk." B. "I am going to stop paying my bills since I won't be around much longer." C. "I wish you would go take care of somebody who actually needs you." D. "I am sure I'm going to be able to continue to care for myself without help."

A. "I am going to order a wheelchair for when I'm unable to walk." The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral response of acceptance.

ATI: A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates an understanding of the teaching about the medication? A. "I should eat a regular diet with normal amounts of salt and fluids." B. "I should discontinue the lithium when I begin to feel better." C. "I need to be careful to avoid becoming addicted to lithium." D. "I can skip a dose of medication if my stomach is upset."

A. "I should eat a regular diet with normal amounts of salt and fluids." The nurse should identify that this statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity.

ATI: A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? A."If you do my homework for me, I won't bother you for the rest of the day." B. "Mom is always upset." C. "It's not the children's fault. It's mine." D. "It's your fault that we're having problems as a family."

A. "If you do my homework for me, I won't bother you for the rest of the day." This is an example of manipulative behavior. It is an example of manipulation when the family member uses a behavior to get what they desire rather than directly asking for what they want.

ATI: A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? A. "It appears as though you would like to open the door." B. "You will feel more comfortable after you've been here for a while." C. "It is okay to not want to be here." D. "You really shouldn't be pushing on the door."

A. "It appears as though you would like to open the door." This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

ATI: A client who has a diagnosis of depression is attending group therapy. During the group meeting the nurse asks each member to identify one gaol for the day. When it's the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? A. Allow the client time to formulate an answer. B. Prompt the client to give a response. C. Move on to the next client. D. Offer the client a suggestion for a goal.

A. Allow the client time to formulate an answer. Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A nurse is caring for an adolescent client with an eating disorder. The client is 64 inches tall and weighs 85 lb. Upon assessment, which of the following manifestations should the nurse recognize are consistent with the admitting diagnosis? Select all that apply. A. Amenorrhea B. Verbalized desire to gain weight C. Altered body image D. Over-exercising E. Bradycardia

A. Amenorrhea C. Altered body image D. Over-exercising E. Bradycardia

A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse. Which of the following should the nurse include in the discussion? Select all that apply. A. Anxiety B. Obsessive-compulsive disorder C. Schizophrenia D. Breathing-related sleep disorder E. Depression

A. Anxiety B. Obsessive-compulsive disorder E. Depression

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate? A. Ask her if she has a plan to commit suicide. B. Recognize the attempt at manipulation and escort her back to her activity. C. Assist her to her room and allow her to rest before resuming activity. D. Notify her family and request a visitor to stay with her until thoughts of suicide are gone.

A. Ask her if she has a plan to commit suicide.

ATI: A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? A. Clang association B. Word salad C. Neologism D. Echolalia

A. Clang association The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have a similar sound.

A nurse is assessing a client who has obsessive-compulsive disorder (OCD) and find that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to A. Decrease anxiety B. Focus on non-threatening tasks C. manipulate others D. decrease time available for interaction with people.

A. Decrease anxiety

A nurse is caring for a client in an urgent care center with traumatic injuries following an assault. She sits quietly and calmly in the exam room. The nurse should recognize this behavior as which of the following? A. Denial B. Displacement C. Introjection D. Undoing

A. Denial

The client, with depressive disorder, is in alcohol withdrawal and reports a recent job loss. Which of the following should be the priority nursing intervention? A. Determine the presence and degree of suicidal risk B. Assist the client to identify negative effects of chemical dependency. C. Identify support groups in the community for long term treatment. D. Refer client to a mental health care provider for evaluation and treatment.

A. Determine the presence and degree of suicidal risk

Which of the following are expected findings in the client with obsessive-compulsive disorder (OCD)? Select all that apply. A. Difficulty relaxing B. Irrational fear of certain objects C. Rule-conscious behavior D. Unaware of compulsions E.Perfectionist behavior

A. Difficulty relaxing C. Rule-conscious behavior E.Perfectionist behavior

ATI: A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. which of the following actions should the nurse take? A. Do not administer the lorazepam. B. Request a prescription for IV lorazepam. C. Request that another nurse attempt to administer the lorazepam. D. Place the lorazepam in the client's food.

A. Do not administer the lorazepam. Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment. Therefore, the nurse should hold the medication and document the client's refusal.

ATI: A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? A. Emotional lability B. Self-sacrificing C. Suspicious of others D. Grandiosity

A. Emotional lability Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances.

ATI: A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to drink 125 mL of fluid each hour while awake. B. Allow the client to eat independently in their room. C. Weigh the client twice weekly. D. Measure the client's vital signs once each day.

A. Encourage the client to drink 125 mL of fluid each hour while awake. The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.

ATI: A nurse is documenting admission assessment findings for a client who has a major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply) A. Feelings of hopelessness B. Pressured speech C. Grandiosity D. Anhedonia E. Flat facial expression

A. Feelings of hopelessness - The nurse should document feelings of hopelessness as a clinical manifestation of major depressive disorder. D. Anhedonia - The nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorder. E. Flat facial expression - The nurse should document a flat facial expression as a clinical manifestation of major depressive disorder.

The depressed client refuses to participate in group therapy or perform ADLs. Which statement by the nurse is appropriate? A. I will assist you in getting out of bed and getting dressed. B. You can remain in bed until you feel well enough to join the milieu. C. The unit rules state you may not remain in bed. D. If you don't participate in your care, you will not get better.

A. I will assist you in getting out of bed and getting dressed.

The client begins to make sexual advances toward the nurse. Which of the following is an appropriate statement by the nurse? A. I'm going to leave now, and I'll return in one hour to spend time with you then. B. I'm sure you don't intend to behave this way so I'm going to ignore this behavior C. I'm very flattered but I am married and cannot engage in this behavior. D. I'm curious as to why you are behaving this way. Can you please explain it to me?

A. I'm going to leave now, and I'll return in one hour to spend time with you then.

ATI: A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? A. Increased creatine phosphokinase (CPK) B. Increased low-density lipoproteins (LDL) C. Decreased fasting blood glucose D. Decreased aspartate aminotransferase (AST)

A. Increased creatine phosphokinase (CPK) An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

ATI: A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? A. Inform the client that this admission is confidential. B. Introduce the client to other clients in the day room. C. Assist the client in facilitating behavioral change. D. Determine coping strategies that the client has used in the past.

A. Inform the client that this admission is confidential. According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.

A nurse in a psychiatric unit is caring for a client who is being admitted involuntarily after attacking a neighbor. The nurse knows that the client can be kept on the 72 hour hold is over if the client A. Is a danger to herself or others B. Is unwilling to accept that treatment is needed C. Does not have anyone that she could stay with D. Is financially incapable of paying for prescription medications

A. Is a danger to herself or others

Which of the following is the highest priority nursing intervention for the client who has depression? A. Monitor for risk of self harm B. Administer prescribed antidepressants C. Encourage adequate fluid intake D. Assist with activities of daily living

A. Monitor for risk of self harm

ATI: A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take? A. Move the client who has bipolar disorder to a private room. B. Administer sleep medication to the client who has bipolar disorder. C. Move the client who has severe depression to a private room. D. Administer sleep medication to the client who has severe depression. E. F.

A. Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.

A nurse is assessing for the presence of extrapyramidal side effects (EPSs) in a client taking chlorpromazine (Thorazine). Which of the following findings should the nurse recognize as EPSs? Select all that apply. A. Muscle contractions of the neck B. Fighting behavior C. Fluctuating vital signs D. Impaired gait E. Sexual dysfunction

A. Muscle contractions of the neck B. Fighting behavior D. Impaired gait

A nurse in the ED is caring for a client taking haldol for the past 3 months. The client's temperature is 102 F, BP 150/110, and has tachycardia. The nurse should know that these indicate a diagnosis of Arganulocytosis A. Neuroleptic malignant syndrome (NMS) B. Hypertensive crisis C. Tardive dyskinesia

A. Neuroleptic malignant syndrome (NMS)

A nurse is caring for a client with a serum lithium level of 2.0 mEq/L. which of the following is the priority action? A. Notify the provider of this toxic blood level. B. Continue to monitor this expected maintenance level. C. Anticipate increasing the dose as this value is subtherapeutic D. Anticipate decreasing the dose because this is slightly above therapeutic level.

A. Notify the provider of this toxic blood level.

ATI: A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.) A. Occupational therapy B. Meal delivery services C. Speech-language pathologist D. Physical therapy E. Home health services F.

A. Occupational therapy -An occupational therapist can assist the client to perform ADLs. B. Meal delivery services - Meal delivery services are necessary due to the client's difficulty performing ADLs . D. Physical therapy - A physical therapist can assess the client's mobility needs and assist with ADLs. E. Home health services - Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

ATI: A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? A. Promote the use of music to compete with the client's auditory hallucinations. B. Inform the client that the auditory hallucinations are not real. C. Avoid asking the client if they are experiencing auditory hallucinations. D. Instruct the client on the use of voice recognition regarding auditory hallucinations.

A. Promote the use of music to compete with the client's auditory hallucinations. Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level.

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following is the highest priority? A. Protecting the client from injury B. Determining the cause of the client's anxiety C. Ensuring that the client feels safe D. Identifying the client's coping skills.

A. Protecting the client from injury

ATI: A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver A. Respite care B. Partial hospitalization C. Adult daycare program D. Geropsychiatric unit

A. Respite care Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves.

Which of the following is an expected finding for a client with major depressive disorder (MDD)? A. Significant change in weight B. Hyperexcitability C. Exaggerated response of pleasure to stimuli. D. Attention seeking behavior

A. Significant change in weight

ATI: A nurse in an outpatient mental health setting is collecting a health history for a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client which of the following supplements interacts adversely with paroxetine. A. St. John's wort B. Saw palmetto C. Echinacea D. Ginkgo

A. St. John's wort St. John's wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.

Which of the following would you recognize as manic behavior? Select all that apply. A. Talking in rapid, continuous speech B. Interacting with others in a flirtatious way C. Spending large sums of money D. Sleeping for long periods of time. E.Dressing in black or grey clothing

A. Talking in rapid, continuous speech B. Interacting with others in a flirtatious way C. Spending large sums of money

ATI: During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on he client's nonverbal behaviors? A. The client is interested in what the nurse is saying. B. The client is attempting to manipulate the nurse. C. The client is physically attracted to the nurse. D. The client needs to feel accepted by the nurse.

A. The client is interested in what the nurse is saying. The client's posture and eye contact demonstrates an interest in the interview and what the nurse is saying.

A nurse is caring for a client diagnosed with depression. His spouse asks the nurse about possible side effects of electroconvulsive therapy (ECT.) After explaining that ECT will not cause brain damage, what additional information should the nurse offer? A. The main side effects are temporary, and may include mild confusion,slight headache, and short term memory problems. B. Most have no adverse effects from this treatment, although muscle cramping my result from the induced seizure. C. Some have been known to have a myocardial infarction, but we will monitor him closely to be certain this doesn't happen. D. The common side effects are related to the use of anesthesia.

A. The main side effects are temporary, and may include mild confusion,slight headache, and short term memory problems.

ATI: A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? A. WBC count 2,500/mm3 B. Hgb 11.5 mg/dL C. Platelets 150,000/mm3 D. RBC count 3.5 million/mm3

A. WBC count 2,500/mm3 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

A nurse is caring for a client who is receiving chlorpromazine (Thorazine) and is given a pass to attend a family outing on a sunny day. Which of the following is most important for the nurse to include in the client's teaching about the side effects of chlorpromazine? A. Wear a hat and a long-sleeved shirt. B. Suck on hard candies. C. Drink plenty of fluids. D. Limit alcoholic beverages to one beer only

A. Wear a hat and a long-sleeved shirt.

A nurse in a hospital is caring for a client who has agoraphobia. The nurse should evaluate that the client is making progress when the client is able to attend A. a picnic in a local park B. daily group therapy sessions C. recreational therapy in the day room. D. lunch in the hospital cafeteria with family.

A. a picnic in a local park

You should rest until you feel able to join the group. The client who is bipolar is being discharged on lithium. The nurse understands that lithium toxicity can occur is the client A. engages in strenuous exercise. B. discontinues the drug abruptly. C. increases sodium intake. D. eats food high in tyramine.

A. engages in strenuous exercise.

ATI: A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? A.Nonmaleficence B. Veracity C. Justice D. Autonomy

A.Nonmaleficence It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit.

A nurse is caring for a patient with paranoid schizophrenia. Which of the following interventions should be included in the plan of care? A. rotate staff assignments for this client B. use touch to calm the client during periods of anxiety C. Remove medication from sealed packages at the client's bedside D. Assign assistive personnel to feed the client

C. Remove medication from sealed packages at the client's bedside

ATI: A nurse is assessing a school-age child who has a conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? A. Feelings of remorse B. Extended periods of depression C. Deficits in intellectual functioning D. Aggression toward animals

Aggression toward animals The nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder.

ATI: A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will spend extra time at work to keep from feeling depressed." B. "I will talk about my feelings with a close friend." C. "I will be able to learn how to prevent my partner's attacks." D. "I will use meditation instead of taking my antidepressant."

B. "I will talk about my feelings with a close friend." Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

ATI: A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? A. "You probably want to hold your baby." B. "I'll stay with you just in case you want to talk." C. "I know how you must be feeling." D. "It hurts now, but things will be better soon."

B. "I'll stay with you just in case you want to talk." This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.

ATI: A nurse is planning care for a client who has depression and has made frequent suicide attempts. which of the following statements indicates the client has a decreased risk for suicide? A."I'm relieved now that my financial affairs are in order." B. "It is easier to talk about my feelings now." C. "Suddenly I have enough energy to do anything I want." D. "Thank you for always taking such good care of me."

B. "It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome.

ATI: A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? A."This disease will increase our child's risk for high blood pressure." B. "It is important for our child to have regular dental checkups." C. "We need to weigh our child daily for several weeks, then once per week." D. "Bleeding during our child's periods will increase because of this disease."

B. "It is important for our child to have regular dental checkups." For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa

ATI: A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? A. "She works so hard at ballet. Will she still be able to perform?" B. "She won't let me take the trash from her room. I'm concerned about what she has in there." C. "She told me she was tired, so I did her chores for her today." D. "She is happier with her appearance now that she's lost some weight."

B. "She won't let me take the trash from her room. I'm concerned about what she has in there." The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.

ATI: A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? A. "Succinylcholine will enhance the therapeutic effects of this treatment." B. "Succinylcholine is given to reduce muscle movements during therapy." C. "Succinylcholine will decrease the anxiety level that you might experience with this treatment." D. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure."

B. "Succinylcholine is given to reduce muscle movements during therapy." Succinylcholine is a muscle-paralyzing agent that will decrease muscle movement during the procedure so the client is less likely to be injured.

ATI: A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? A. "You might notice an increase in saliva while taking this medication." B. "You might experience difficulties with sexual functioning while taking this medication." C. "You should expect an improvement in symptoms of depression in 3 to 4 days." D. "You may notice a temporary ringing in the ears when starting this medication."

B. "You might experience difficulties with sexual functioning while taking this medication." Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs.

ATI: A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A."You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C. "You don't want to look at yourself because you think you are fat." D. "You and I can work together to overcome your fears of gaining weight."

B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

ATI: A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity A. A client who has a fasting blood glucose level of 80 mg/dL B. A client who has a sodium level of 128 mEq/L C. A client who has a BUN of 18 mg/dL D. A client who has a potassium level of 3.6 mEq/L

B. A client who has a sodium level of 128 mEq/L A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.

ATI: A nurse is caring for a group of clients. Which of the following findings should the nurse report? A. A client who is taking clozapine and has a WBC count of 7,500/mm3 B. A client who is taking lamotrigine and has developed a rash C. A client who is taking valproate and has a platelet count of 150,000/mm3 D. A client who is taking lithium and has a lithium level of 1.2 mEq/L

B. A client who is taking lamotrigine and has developed a rash Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately.

ATI: A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A. A school-age child who has bruises on the knees B. An older adult client who is bedbound and has a stage IV pressure ulcer C. An adolescent who has a vaginal candida infection D. A young adult who is pregnant and has a sprained ankle

B. An older adult client who is bedbound and has a stage IV pressure ulcer A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

ATI: A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement A. Tell the client to talk less or risk being removed from the meeting. B. Ask group members to discuss their feelings about this client's monopolizing behavior. C. End the group meeting and take the client aside to discuss the disruptive behavior. D. Focus on other group members and ignore the client who is doing all the talking.

B. Ask group members to discuss their feelings about this client's monopolizing behavior. Ask group members to discuss their feelings about this client's monopolizing behavior. This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

ATI: A nurse is caring for a clinet who is experiencing a panic attack. Which of the following actions should the nurse take? A. Orient the client to person, place, and time. B. Assist the client with deep-breathing exercises. C. Calm the client by using therapeutic touch. D. Have the client sit alone in a quiet room.

B. Assist the client with deep-breathing exercises. Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

ATI: A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hr ago following a motor vehicle crash. The client's admission blood alcohol level was 325 mg/dl. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? A. Somnolence B. Blood pressure 154/96 mm Hg C. Pinpoint pupils D. Blood glucose 210 mg/dL

B. Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.

ATI: A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include? A. Additional acute episodes of depression are unlikely following inpatient care. B. Early identification of changes, such as decreased social involvement, is important. C. Medication compliance will prevent further need for inpatient hospitalization. D. It is helpful to regularly reinforce to the client that things will get better. E. F.

B. Early identification of changes, such as decreased social involvement, is important. Decreased social involvement is a manifestation of depression, and early identification of findings can lead to early intervention.

ATI: A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? A. Have the client participate in a morning aerobics group. B. Encourage frequent rest periods throughout the day. C. Provide a distraction such as television at night. D. Offer the client hot chocolate at bedtime.

B. Encourage frequent rest periods throughout the day. A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.

A nurse is caring for a client who has anorexia nervosa and over-exercises to avoid gaining weight. Which is the following nursing interventions is appropriate? A. Praise the client for looking at herself in the mirror. B. Establish a contract with the client requiring her to talk to the nurse when she feels the urge to exercise. C. Confront the client about the damage over-exercising can do to her body. D. Restrict the client from being weighed

B. Establish a contract with the client requiring her to talk to the nurse when she feels the urge to exercise.

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following interventions are appropriate? Select all that apply. A. Avoid eye contact to prevent escalation of anxiety. B. Establish rapport with the client C. Identify the cause of the anxiety. D. Validate the client's feelings E. Develop a flexible crisis intervention plan

B. Establish rapport with the client C. Identify the cause of the anxiety. D. Validate the client's feelings

ATI: A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? A. Provide teaching about the use of positive coping mechanisms. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

B. Establish screening programs to identify at-risk clients. This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs.

A nurse is caring for a client who has bipolar disorder and is hospitalized for a severe depressive episode. The client has been taking citalopram (Celexa) for 2 weeks and reports sleeping better and having improved appetite, but still feels hopeless. Which of the following is an appropriate nursing action? A. Speak to the provider about increasing the dose of citalopram B. Explain that antidepressants often take several weeks to be fully effective C. Notify the provider so the client can be prescribed a different medication D. Recommend a sleep study be done on the client

B. Explain that antidepressants often take several weeks to be fully effective

ATI: A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in effect within 30 to 60 min after taking the medication B. Greater risk of attempting suicide as effect and energy improve C. Onset of frequent, loose stools D. Development of physiologic dependence on the medication

B. Greater risk of attempting suicide as effect and energy improve The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment.

ATI: A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members A. Response prevention B. Guided imagery C. Aversion therapy D. Light therapy E. F.

B. Guided imagery Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder.

A nurse is observing a newly licensed nurse as he provides family therapy for a client regarding relationship concerns with his spouse. Which of the following statements by the new nurse requires intervention? A. Tell me about the concerns that you have regarding your relationship. B. I think you should try to see your wife's point of view as well as your own. C. We should invite your wife to be a part of our discussion D. Relationship difficulties are stressful and require effort to resolve.

B. I think you should try to see your wife's point of view as well as your own.

ATI: A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of the safety plan? A. Develop a code word that means "time to go." B. Identify signs of escalation of violence. C. Have a predetermined place to go in the event of violence. D. Keep a hidden packed bag of necessities.

B. Identify signs of escalation of violence. It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.

ATI: A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? A. Include a liquid supplement with meals. B. Identify the client's trigger foods. C. Allow the client at least 1 hr for each meal. D. Weigh the client at bedtime each day.

B. Identify the client's trigger foods. The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.

ATI: A nurse is teaching the partner of a clinet who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider? A. Obsessive attention to detail B. Inability to sleep C. Reports of fatigue D. Isolation from others

B. Inability to sleep During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.

ATI: A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? A. Advise the client to take frequent sips of water. B. Instruct the client to avoid driving during initial therapy. C. Consult a dietitian for a calorie-controlled diet plan. D. Recommend that the client exercise regularly. E. F.

B. Instruct the client to avoid driving during initial therapy. The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.

ATI: A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? A.Sedation B. Rhinorrhea C. Bradycardia D. Hypothermia E. F.

B. Rhinorrhea The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.

ATI: A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? A. Behave in a friendly manner toward the client. B. Set realistic limits on the client's behavior. C. Show respect for the client's need for isolation. D. Act as a role model for assertiveness.

B. Set realistic limits on the client's behavior. Clients who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should establish clear limits on specific aggressive and demanding behaviors.

ATI: A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? A. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. B. The client reports an inability to breathe easily. C. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. D. The client reports having recently started smoking cigarettes.

B. The client reports an inability to breathe easily. Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider.

ATI: A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency. A. The client is exhibiting echolalia. B. The client reports command hallucinations. C. The client reports loss of motivation. D. The client is exhibiting blunted affect.

B. The client reports command hallucinations. The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others.

ATI: A nurse is discussing a 12-step program with a client who has an alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? A. The program will help the client accept responsibility for the disorder. B. The client should obtain a sponsor before discharge for an increased chance of recovery. C. The client will need to identify individuals who have contributed to the disorder. D. The program will need a prescription from the client's provider prior to attendance.

B. The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program.

A nurse is caring for a client admitted with acute psychosis, being treated with haloperidol (Haldol.) The nurse should suspect tardive dyskinesia as an adverse reaction when the client exhibits which of the following? Select all that apply. A. Urinary retention and constipation B. Tongue twisting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Extreme sedation and lethargy F.Repetitive involuntary movements

B. Tongue twisting and lip-smacking D. Facial grimacing and eye blinking F. Repetitive involuntary movements

ATI: A nurse is admitting a client who has an alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? A. "I put in extra hours at work so I won't think about drinking." B. "I know that wine is good for my heart, so that's why I drink some each evening." C. "I make up for my drinking by taking my partner on nice vacations." D. "I am able to go to work every day, so I don't have a problem."

By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder.

ATI: A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. which of the following statements should the charge nurse make? A. "Clients can't refuse to take medications if they are admitted involuntarily." B. "You can notify a client's family if they are admitted involuntarily." C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." D."You can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions."

C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures.

ATI: A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify which of the following statements by the client partner indicates an understanding of the teaching. A. "I will avoid social events until my partner has completed treatment." B. "It is important for me to focus my attention on my partner's addiction." C. "I will not take charge of my partner's work responsibilities." D. "I want my partner to promise to change addictive behaviors."

C. "I will not take charge of my partner's work responsibilities." The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

ATI: A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders, which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use the same plan of care and interventions for each client who has depression." B. "Each nurse will develop a separate plan of care for each client who has depression." C. "I will update the plan of care as a client's manifestations of depression change." D. "An assistive personnel can use the plan of care for client teaching."

C. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change.

ATI: A nurse is caring for an older adult client who begins to cry and states, "I knew god would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make? A. "Why do you think you deserve this punishment?" B. "Don't worry about being punished by God." C. "Let's talk about what is upsetting you." D. "You shouldn't say things that will upset you so much."

C. "Let's talk about what is upsetting you." The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

ATI: A nurse is caring for four clients in an emergency department. The nurse should identify which of the following clients can give informed consent. A. A 17-year-old client who lives with friends B. A 50-year-old client who has a blood alcohol level of 80 mg/dL C. A 35-year-old client who has major depressive disorder D. A 65-year-old client who just received a dose of morphine

C. A 35-year-old client who has major depressive disorder A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.

ATI: A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? A. A client refuses electroconvulsive therapy after signing the consent form. B. A client who was voluntarily admitted left the unit against medical advice. C. A client was administered one-half of the prescribed dose of medication. D. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.

C. A client was administered one-half of the prescribed dose of medication. An incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form.

ATI: A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? A. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. B. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. C. A client who has borderline personality disorder threatened to harm their roommate. D. An adolescent client who has anorexia nervosa has a BMI of 17.

C. A client who has borderline personality disorder threatened to harm their roommate. Manifestations of borderline personality disorder include disturbed interpersonal relationships accompanied by threats and other-directed violence. While it is important for the nurse to maintain the client's confidentiality, on occasions when another individual's life might be in danger, the nurse is required by law to report it to authorities.

ATI: A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? A. Delusions B. Neologisms C. Anhedonia D. Echopraxia

C. Anhedonia Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

ATI: A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? A. Complete documentation about the client's status every hour while they are in restraints. B. Maintain the client in restraints for a minimum of 4 hr. C. Apply restraints when other means of managing the client's behavior have failed. D. Request that the provider assess the client within 8 hr of the application of restraints.

C. Apply restraints when other means of managing the client's behavior have failed. According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.

ATI: A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? A. Call the family member to the side to inquire if they have questions or concerns about the treatment plan. B. Advise the family member that this treatment plan has been developed specifically for the client to follow. C. Ask the family member if they have any thoughts or questions about the treatment plan. D. Document that the family member does not support the medication treatment plan.

C. Ask the family member if they have any thoughts or questions about the treatment plan. This action involves the family member and allows them a venue to communicate about the client's medication treatment plan.

ATI: A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? A. Offering self B. Use of Silence C. Attention to body language D. Reflection of feelings

C. Attention to body language Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.

ATI: A nurse on a mental health unit observes a client who has acute mania hit another clinet. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who has was hit for injuries. E. F.

C. Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A client with schizophrenia is experiencing a variety of hallucinations. Which of the following hallucinations is the priority concern? A. Visual hallucination B. Gustatory hallucination C. Command hallucination D. Tactile hallucination

C. Command hallucination

ATI: A nurse is provider's office is collecting a health history from the guardian of the school age child who has been taking atomoxetine. which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? A. Reduced appetite B. Fatigue C. Dark urine D. Sweating

C. Dark urine The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death. Therefore, this is the nurse's priority finding.

ATI: A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A. Repeatedly talks about the traumatic incident B. Sleeps excessively C. Experiences feelings of isolation D. Uses repetitive speech

C. Experiences feelings of isolation The nurse should expect clients who have PTSD to feel estranged and detached from others.

ATI: A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following is an expected adverse effect that might have caused the client to stop taking medication. A. Sore throat B. Photophobia C. Hand tremors D. Constipation

C. Hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication.

A nurse is caring for a client with depression. The client refuses to get out of bed, go to activities, or participate in any unit programs. Which of the following statements is appropriate? A. You really need to follow the rules of the unit and get out of bed. B. If you do not get out of bed, you will not receive your meal. C. I will help you get ready and then you can rest after activities.

C. I will help you get ready and then you can rest after activities.

Which of the following statements by a client with mood disorder indicates readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always have my mother to help me. C. I will take my medicines as I should, and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything.

C. I will take my medicines as I should, and know to call the number you gave me if I have bad thoughts.

A nurse is assessing an adolescent client with anorexia. Which of the following client statements is a sign of cognitive distortion? A. I like to cut my food into small portions B. I really need to get in shape C. If I eat one piece of candy, I may as well eat ten D. I cant afford to gain weight

C. If I eat one piece of candy, I may as well eat ten

A nurse is teaching a newly licensed nurse about electroconvulsive therapy (ECT.) Which of the following statements by the new nurse indicates understanding? A. ECT is an effective treatment for personality disorders B. I should monitor the client closely for hypotension following the ECT C. Informed consent should be obtained prior to ECT. D. It is a myth that clients experience seizures during ECT.

C. Informed consent should be obtained prior to ECT.

The client with bipolar disorder approaches the nurse and reveals fresh, self-inflicted superficial cuts going up and down his right arm. Which of the following actions should the nurse perform first? A. Implement the client's behavioral modification plan B. Document the size and location of the cuts C. Inspect the cuts for debris. D. Administer a tetanus antitoxin. E. F.

C. Inspect the cuts for debris.

ATI: A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? A. Raise the pitch of the voice when speaking to the client. B. Begin the interview by explaining the plan of care. C. Interview the client in a private setting. D. Ask the client to complete a detailed questionnaire.

C. Interview the client in a private setting. The nurse should interview clients in a private place when asking questions regarding client health.

A nurse drives up to the house of her client, who has schizophrenia with manic episodes. This is the nurse's fifth visit. On this occasion, the client is sitting on his front porch with a shotgun in his arms. Which of the following is an appropriate action by the nurse? A. Honk the car horn to get the client's attention. B. Calmly speak the client's name out of the car window C. Keep driving in a path going away from the client's house. D. Stop the car in the client's driveway and call the authorities.

C. Keep driving in a path going away from the client's house.

A nurse is caring for a client hospitalized with bipolar disorder. The client's provider prescribes valproate (depakote). Which of the following instructions should the nurse give about this medication? A. Thyroid function tests must be done every 6 months B. A pretreatment electroencephalogram (EEG) will be done. C. Liver function and complete blood counts must be monitored D. White blood count must be monitored weekly.

C. Liver function and complete blood counts must be monitored

ATI: A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to participate in group therapy. B. Instruct the client to avoid napping during the day. C. Offer the client high-calorie finger foods frequently. D. Decrease the client's daily fiber intake.

C. Offer the client high-calorie finger foods frequently. The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration.

ATI: A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue. A. An adolescent family member who questions parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household E. F.

C. Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.

ATI: a nurse is caring for an older adult client who is experiencing delirium. which of the following interventions should the nurse include in the clients plan of care A. Offer the client various choices for meal selection. B. Assign different nursing personnel for each shift. C. Permit the client to perform daily rituals to decrease anxiety. D. Maintain an environment that has low lighting.

C. Permit the client to perform daily rituals to decrease anxiety. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

ATI: A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following A.Schedule the client for group therapy sessions. B. Maintain consistent rules. C. Provide frequent high-calorie snacks. D. Avoid the use of value judgments.

C. Provide frequent high-calorie snacks. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.

ATI: A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditions. which of the following client behaviors indicates the effectiveness of the therapy? A. Controls anger outbursts to avoid being placed in seclusion B. No longer exhibits a fear of social or public situations C. Refrains from manipulating others to earn dining room privileges D. Imitates the therapist's use of a relaxation technique

C. Refrains from manipulating others to earn dining room privileges The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

A nurse is counseling a client for management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need to be taken care of." The nurse identifies this behavior as an example of which of the following defense mechanisms. A. Dissociation B. Introjection C. Regression D. Repression

C. Regression

ATI: A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit which of the following interventions should the nurse include in the plan? A. Document the client's behavior every 8 hr. B. Limit the client's fluid intake to 50 mL/hr. C. Renew the prescription for the client every 4 hr. D. Toilet the client every 4 hr.

C. Renew the prescription for the client every 4 hr. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

ATI: A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take? A. Assist the client in identifying personal areas of strength. B. Encourage the client to talk about experiences during the deployment. C. Stay with the client when flashbacks occur. D. Teach the client stress-management techniques.

C. Stay with the client when flashbacks occur. The greatest risk to this client is injury that can occur during a flashback; therefore, the priority intervention for the nurse is to remain with the client and offer reassurance and support when flashbacks occur.

ATI: A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? A. Male gender B. Hyperthyroidism C. Substance use disorder D. Being married

C. Substance use disorder The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

ATI: A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? A. Encourage the parents to avoid discussing the death with their other children to protect their feelings. B. Recommend each parent grieve in private to avoid hindering each other's healing. C. Suggest forming a weekly support group for parents who have experienced the death of a child. D. Advise the parents to begin counseling if they are still grieving in a few months.

C. Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child.

ATI: A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate. A. Weight gain B. Tinnitus C. Tachycardia D. Increased salivation

C. Tachycardia The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

The nurse is caring for a client who is in the manic phase of bipolar disorder. the client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? A. Recommend a game of table tennis with another client. B. Suggest the client exercise on a stationary bike. C. Take the client outside for a walk. D. Do nothing, as the client's behavior is considered therapeutic. E. F.

C. Take the client outside for a walk.

ATI: A nurse is assessing a client for risk factors for the development of depression. The nurse should identify which of the following factors places the client at an increased risk for depression. A. The client is married. B. The client recently received a promotion at work. C. The client has COPD. D. The client is a male.

C. The client has COPD. The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.

ATI: A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? A. The client will take prescribed medications as scheduled. B. The client will express feelings of frustration. C. The client will refrain from self-mutilation. D. The client will participate in group therapy.

C. The client will refrain from self-mutilation. The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the client to refrain from self-mutilation.

Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? A. The ritualistic behavior provides sexual satisfaction. B. The client performs ritualistic behavior to boost self-esteem. C. The ritualistic behavior temporarily relieves anxiety. D. The client performs ritualistic behavior to decrease feelings of shame.

C. The ritualistic behavior temporarily relieves anxiety.

ATI: A charge nurse is preparing an education session for a group of newly licensed nurses to review the client's rights under the law. Which of the following statements should the nurse make A." Information regarding clients should remain confidential until after their death." B. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." C. "As long as client identity is disguised, their health information can be shared between professionals on the internet." D. "In the event a client threatens harm to others, medications can be administered without consent."

D. "In the event a client threatens harm to others, medications can be administered without consent." The charge nurse should inform the participants that medications can be administered without consent if a client threatens harm to others. The nurse should always protect the health and safety of their clients, even when a client's safety is threatened by another client.

ATI: A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? A. "It will be better for you to keep busy to avoid thinking about your child's death." B. "You will complete the grieving process about a year after your child's death." C. "The grief process will start once your child actually dies." D. "It is not uncommon to feel angry toward yourself or others."

D. "It is not uncommon to feel angry toward yourself or others." Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.

ATI: A nurse on an acute mental health facility is receiving a change-of-shift report of four clients. Which of the following clients should the nurse assess first? A. A client who does not recognize familiar people B. A client who cannot verbalize their needs C. A client who is awake and disoriented at night D. A client who is experiencing delusions of persecution

D. A client who is experiencing delusions of persecution The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first.

ATI: A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse plan to see first? A. A client who has avoidant personality disorder and refuses to attend group therapy B. A client who has bipolar disorder and reports being kidnapped by aliens overnight C. A client who is taking bupropion and reports having insomnia the past 2 nights D. A client who is taking clozapine and reports a sore throat and chills

D. A client who is taking clozapine and reports a sore throat and chills When using the urgent vs. nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect that causes neutropenia. The nurse should withhold the medication and notify the provider of these findings.

A nurse is caring for a client who is cognitively impaired. Which of the following is a therapeutic environment for this client? A. A bright colorful room close to the nursing station B. A room with little furniture and many safety devices. C. A clean room with monitors and a TV D. A quiet room with personal belongings

D. A quiet room with personal belongings

ATI: A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? A. Blurred vision B. Orthostatic hypotension C. Dry mouth D. Acute dystonia

D. Acute dystonia The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

A community health nurse is assigned to administer an IM medication for control of hallucinations to a client with schizophrenia. The prior nurse reports the client will let the nurse in her house only if the nurse carries a public health-issued blue bag and wears black pants. Which of the following is an appropriate action by the nurse? A. Telephone the client and tell her the new nurse will be wearing white pants. B. Arrive as scheduled carrying only a stethoscope, vial, alcohol wipe and medication syringe. C. Arrive as scheduled with a police officer D. Arrive carrying a blue bag and wearing black pants.

D. Arrive carrying a blue bag and wearing black pants.

ATI: A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take? A. Tell the client that the voices do not really exist. B. Touch the client to help reduce feelings of anxiety. C. Instruct the client to go to a quiet room when the voices start talking. D. Ask the client what the voices are saying.

D. Ask the client what the voices are saying. It is important for the nurse to ask the client directly about the hallucinations to determine if the client or others are at risk for injury.

ATI: A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify which of the following treatment options can offer interdisciplinary services for the client at home. A. Community mental health center B. Mental Health Day program C. Partial hospitalization program D. Assertive community treatment

D. Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

ATI: A nurse is providing teaching to a client who is beginning to undergo light therapy at home. Which of the following information should the nurse include in the teaching? A. Ensure a family member can be present during treatment. B. Increase fluid intake for 24 hr before the treatment starts. C. Change position slowly when the treatment is complete. D. Avoid looking directly at the light during treatment.

D. Avoid looking directly at the light during treatment. Light therapy, or phototherapy, can cause sensitivity to light. To minimize this effect, the client should avoid looking directly at the light.

ATI: A nurse is admitting a female client who has anorexia nervosa. which of the following manifestations should the nurse expect during the admission assessment A. Diarrhea B. Heavy menstrual C. Tachycardia D. Orthostatic hypotension

D. Orthostatic hypotension Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.

ATI: A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. which of the following tasks should the nurse assign to the LPN A. Obtain the weight of a client who has bipolar disorder and is experiencing mania. B. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. C. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. D. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

D. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound.

ATI: A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others? A. Inability to communicate with others B. Feelings of absence of self-worth C. Lack of motivation to perform daily tasks D. Command hallucinations

D. Command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.

Which findings support the diagnosis of hypochondriasis? A. Prior physical health followed by the need for two surgeries within the last three months. B. Obsession over a fictitious defect in physical appearance. C. Sudden unexplained loss of peripheral sensation D. Constant worry about the undiagnosed presence of a terminal illness.

D. Constant worry about the undiagnosed presence of a terminal illness.

A nurse is completing an admission assessment for a client who has depression. Findings include an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following is an appropriate intervention to include in the plan of care? A. Discourage rest only at bedtime B. Instruct family to avoid visiting during mealtimes C. Offer frequent low-calorie snacks D. Develop a structured routine for the client to follow

D. Develop a structured routine for the client to follow

A nurse is assessing a client receiving treatment for schizophrenia with the typical antipsychotic fluphenazine (prolixin) for 12 months. The nurse observes fine, fasciculating tongue movements and associates this finding with which of the following? A. A drug food reaction to grapefruit juice B. The client has missed several doses of medication C. Early symptoms of neuroleptic malignant syndrome (NMS) D. Early symptoms of tardive dyskinesia (TD)

D. Early symptoms of tardive dyskinesia (TD)

ATI: A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted E. F.

D. Easily distracted Extreme distractibility is a hallmark manifestation of delirium.

A nurse in the psychiatric unit is caring for a client with moderate anxiety disorder. Which measures should the nurse include in the immediate plan of care? A. Circumvent a discussion about concerns. B. Remain near the client C. Encourage the client to sit for a while D. Foresee anxiety-provoking circumstances

D. Foresee anxiety-provoking circumstances

ATI: A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? A. Inability to recognize family members B. Chooses clothing that is inappropriate for the weather C. Exhibits a change in personality D. Frequently misplaces objects

D. Frequently misplaces objects According to evidence-based practice, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur.

ATI: A home health nurse is assessing an older adult client whose sibling is the primary caregiver. which of the following findings should the nurse identify as a possible indicator of neglect A. Increased confusion B. Sleep disturbances C. Cluttered environment D. Inappropriate dress

D. Inappropriate dress Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

ATI: a school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the client is experiencing post-traumatic stress disorder (PTSD)? A. Clinging behaviors directed toward a teacher B. Increased time spent sleeping C. Intense focus on schoolwork D. Lack of interest in an upcoming holiday

D. Lack of interest in an upcoming holiday The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events such as holidays.

ATI: A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? A. Panic B. Moderate C. Severe D. Mild

D. Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.

ATI: A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? A. Administer phenytoin 30 min prior to the procedure. B. Instruct the client to expect a headache following the procedure. C. Place the client in four-point restraints prior to the procedure. D. Monitor the client's cardiac rhythm during the procedure.

D. Monitor the client's cardiac rhythm during the procedure. The seizure-induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram.

ATI: A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A.Lansoprazole B. Naproxen C. Magnesium hydroxide D. Phenylephrine

D. Phenylephrine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

ATI: A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? A. Encourage the expression of feelings. B. Support the child's attendance at an assertiveness training group. C. Assist the child in performing relaxation breathing. D. Reduce environmental stimuli.

D. Reduce environmental stimuli. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

ATI: A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as a priority? A. Decrease distractions during meal times. B. Provide positive feedback when the child completes a task. C. Clearly identify consequences for unacceptable behavior. D. Remove unnecessary equipment from the child's surroundings.

D. Remove unnecessary equipment from the child's surroundings. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

ATI: A nurse is caring for a client in a mental health facility. The nurse overhears another staff member making derogatory comments to the client. Which of the following actions should the nurse take? A. Confront the staff member. B. Encourage the client to report the incident. C. Document the incident in the client's health record. D. Report the occurrence to the charge nurse.

D. Report the occurrence to the charge nurse. It is the charge nurse and the nurse manager's responsibility to confront the staff member about the derogatory comments made to the client.

ATI: A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? A. Allowing a client to choose which unit activities to attend B. Attempting alternative therapies instead of restraints for a client who is combative C. Providing a client with accurate information about their prognosis D. Spending adequate time with a client who is verbally abusive

D. Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care.

ATI: A nurse in a mental health clinic is planning care for four clients. which of the following tasks should the nurse delegate to an assistive personnel? A. Discuss outpatient resources with a client who has post-traumatic stress disorder. B. Create a plan of care for a client who is experiencing alcohol withdrawal. C. Explain sleep hygiene to a client who has insomnia. D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes.

D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes. Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and this task does not require assessment or technical skill.

ATI: A nurse is caring for an older client who has dementia and has wandered into the day room looking for their deceased partner. which of the following actions should the nurse take? A. Move the client to a room near the nurses' station. B. Limit visitors until the client is oriented to the environment. C. Tell the client that their partner is deceased. D. Talk with the client about activities they enjoyed with their partner.

D. Talk with the client about activities they enjoyed with their partner. Talking about positive experiences can help distract the client from their disorientation.

A nurse is admitting a client who has multiple trauma after a motor vehicle accident. Shortly after admission, her husband arrives. He is distraught and blames himself for the accident. Which of the following is an appropriate nursing response? A. Don't wory about that. Your wife will be fine. B. I think you should calm down a little before you see your wife. C. Why do you think the accident was your fault? D. Tell me more about your feelings about what happened to your wife.

D. Tell me more about your feelings about what happened to your wife.

A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil, I am God. Open the gate for me!" What following replies by the nurse requires intervention by the charge nurse? A. Tell me who you are I don't understand. B. Can you tell me what that means? C. Are you saying that you are both good and bad? D. There is no gate.

D. There is no gate.

ATI: A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? A. Amenorrhea B. Lanugo C. Cold extremities D. Tooth erosion E. F.

D. Tooth erosion A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

ATI: A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? A. Fear of abandonment B. Motor and verbal tics C. Hostile behavior D.Language delay E. F.

D.Language delay The nurse should identify that language delays are a manifestation of autism spectrum disorder.

ATI: A nurse on a mental health unit is caring for a recently admitted client. Vital Signs 0800:Blood pressure 110/78 mm Hg Heart rate 76/min Respiratory rate 18/min Temperature 37° C (98.6° F) 1200:Blood pressure 116/80 mm Hg Heart rate 88/min Respiratory rate 20/min Temperature 38° C (100.4° F) Assessment Findings: Pick Positive or Negative symptoms - Clang associations (Positive Symptoms/Negative Symptoms) - Absence of intonation in speech (Positive Symptoms/Negative Symptoms) - Catatonia (Positive Symptoms/Negative Symptoms) - Withdrawal from social activities (Positive Symptoms/Negative Symptoms) - Delusions of grandeur (Positive Symptoms/Negative Symptoms) - Alogia (Positive Symptoms/Negative Symptoms)

Positive symptoms, Delusions of grandeur, clang associations, and catatonia are consistent with positive symptoms of schizophrenia. Positive symptoms, the presence of symptoms that are not ordinarily present, include hallucinations, delusions, paranoia, and disorganized or bizarre thoughts, behaviors, or speech. Negative Absence of intonation in speech, alogia, and withdrawal from social activities are consistent with negative symptoms of schizophrenia. Negative symptoms, or the absence of something that should be present, include a lack of goal-directed behavior, a decrease in participation in social activities, and a flat affect.