NSG 4515 EXAM 2: ATI Mental Health Practice Assessment
A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make? A) "Oh, I'm so pleased that you finally put on clean clothes." B) "Why did you wear clean clothes and comb your hair today?" C) "Your mood must be lifting because you have on clean clothes and have combed your hair." D) "I see that you have on clean clothes and have combed your hair."
D) "I see that you have on clean clothes and have combed your hair."
A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching? A) "I should expect to feel better after 24 hours of starting this medication." B) "I should not take this medicine with grapefruit juice." C) "I'll take this medicine with food." D) "I'll take this medicine first thing in the morning."
D) "I'll take this medicine first thing in the morning."
A nurse is caring for a client who was involved in hevay combat and observed wat casualties. The nurse should suspect that the client is suffering from post-traumatic stress disorder (PTSD) if the client makes which of the following statements? A) "I check any room I enter because the enemy is still after me and could be hiding anywhere." B) "My child was born with a birth defect due to an exposure I had overseas." C) "I killed four enemy soldiers with my bare hands and saved my entire battalion." D) "In my dreams, all I can see are the wounded reaching out and trying to grab me."
D) "In my dreams, all I can see are the wounded reaching out and trying to grab me."
A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? A) "Syncope episodes may occur when taking this medication." B) "This medication may cause tachycardia." C) "You should administer the medication each morning." D) "You will need to monitor for constipation."
A) "Syncope episodes may occur when taking this medication."
A nurse is assessing an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following findings should the nurse expect? A) Emotional numbing B) Elevated mood C) Anxiety D) Impulsivity
D) Impulsivity
A nurse is caring for a client who has schizophrenia. Which of the following statement by the client indicates concrete thinking? A) "I am aware that each problem has only one solution." B) "I am a prophet of the most high king." C) "The voices tell me that I must avoid large crowds." D) "I know that you and the other nurses are trying to poison me."
A) "I am aware that each problem has only one solution."
A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued? A) A client who has a WBC of 2,900 cells/mm^3 B) A client who has a hematocrit of 55% C) A client who has a serum potassium of 3.3 mEq/L D) A client who has a BUN of 22 mg/dL
A) A client who has a WBC of 2,900 cells/mm^3
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (SATA) A) Grooming B) Long-term memory C) Support systems D) Affect E) Presence of pain
A) Grooming B) Long-term memory D) Affect
A nurse manager is planning a staff inservice on medical diagnoses that can mimic psychosis. Which of the following should the nurse manager include in the presentation? (SATA) A) Hypothyroidism B) Alzheimer's Disease C) Hyperglycemia D) Encephalitis E) Parkinson's Disease
A) Hypothyroidism B) Alzheimer's Disease D) Encephalitis
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weights 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? A) Identify the client's nutritional status B) Request a mental health consult C) Plan a therapeutic diet for the client D) Provide a structured environment for the client
A) Identify the client's nutritional status
A nurse is caring for a client who has just begin therapy with alprazolam to treat anxiety. The nurse should monitor the client for which of the following adverse effects of this medication? A) Insomnia B) Bradycardia C) Hearing loss D) Hypertension
A) Insomnia
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects? A) Tardive dyskinesia B) Parkinsonism C) Dystonia D) Akathisia
A) Tardive dyskinesia
A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone? A) The Abnormal Involuntary Movement Scale B) The Hamilton Depression Scale C) The Body Attitude Test D) The Recovery Attitude and Treatment Evaluator
A) The Abnormal Involuntary Movement Scale
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make? A) "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." B) "Come with me. Here is a milkshake to drink." C) "We need you to decide what activities you will do today." D) "You will need to leave the dining room right now and go somewhere else to exercise."
B) "Come with me. Here is a milkshake to drink."
A nurse is providing teaching for a client who has schizophrenia and a new prescription for fluphenazine. Which of the following information should the nurse provide? A) "This medication might turn your urine orange." B) "Sleepiness should subside within a week." C) "Stop the medication if hypotension occurs." D) "A low-grade fever is expected with first doses."
B) "Sleepiness should subside within a week."
A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan? A) Contact the 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
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first? A) Discuss alternative coping strategies with the client B) Identify precipitating factors for ritualistic behaviors C) Instruct the client on relaxation techniques for use when anxiety increases D) Provide structured activity schedule for the client
B) Identify precipitating factors for ritualistic behaviors
A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? A) Restrain the child physically B) Ignore the temper tantrums C) Tell the child that temper tantrums are not acceptable D) Distract the child by offering to play a game
B) Ignore the temper tantrums
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (SATA) A) Urinary retention and constipation B) Tongue thrusting and lip smacking C) Fine hand tremors and pill rolling D) Facial grimacing and eye blinking E) Involuntary pelvic rocking and hip thrusting movements
B) Tongue thrusting and lip smacking D) Facial grimacing and eye blinking E) Involuntary pelvic rocking and hip thrusting movements
A nurse is teaching about electroconvulsive therapy (ECT) with a newly licensed nurse. The nurse should identify that the newly licensed nurse understands the teaching when she states that ECT treats which of the following disorders? A) Narcotic addiction B) Vegetative depression C) Personality disorder D) Eating disorder
B) Vegetative depression
A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation? A) "I had a great trip to the Smokey Mountains." B) "Going back to work has been okay." C) "I just don't like going to the movies like I used to." D) "I can't wait to have my family together next weekend."
C) "I just don't like going to the movies like I used to."
A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take? A) Ask the client to create her own schedule of daily activities B) Teach the client to use passive communication when interacting with others C) Determine the client's need for assistance with grooming D) Limit the client's involvement in unit activities
C) Determine the client's need for assistance with grooming
A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out the room yelling, "you are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia? A) Magical thinking B) Delusions of grandeur C) Ideas of reference D) Looseness of association
C) Ideas of reference
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety? A) Mild B) Moderate C) Severe D) Panic
C) Severe
A 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 tablet tennis with another client B) Suggest the client exercise on a stationary bike C) Take the client outside for a walk D) Praise the client's efforts to engage in social interaction
C) Take the client outside for a walk
A nurse is assessing a client who has been taking sertraline for 2 weeks. The nurse should identify which of the following findings as an indication that the medication is effective? A) The client's blood pressure is within the expected reference range B) The client reports a recent weight loss C) The client reports increase in mood D) The client's legs are not swollen
C) The client reports increase in mood
A nurse is reviewing the medical record of a client who has a new prescription for clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to clozapine? A) Asthma B) Fasting blood glucose 120mg/dL C) WBC count 3,300 cells/mm^3 D) Hypertension
C) WBC count 3,300 cells/mm^3
A nurse is teaching the parents of a school-age child who has ADHD about atomoxetine. Which of the following instructions should the nurse include in the teaching? A) "Limit caloric intake to prevent excessive weight gain." B) "Avoid crowds due to the increased risk for infection." C) "Expect hyperactivity as a common adverse effect." D) "Give the dose in the morning to help prevent insomnia."
D) "Give the dose in the morning to help prevent insomnia."
A nurse is collecting data from an adolescent. Which of the following should the nurse identify as the greatest risk for suicide? A) Availability of firearms B) Family conflict C) Homosexuality D) Active psychiatric disorder
D) Active psychiatric disorder
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? A) Sleeping 12 hr or more each day B) Increasing sense of attachment to others C) Constant need to talk about the event D) Increasing feelings of anger
D) Increasing feelings of anger
A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weights 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (SATA) A) Amenorrhea B) Verbalized desire to gain weight C) Altered body image D) Hyperactivity E) Bradycardia
A) Amenorrhea C) Altered body image D) Hyperactivity E) Bradycardia
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (SATA) 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 who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make? A) "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." B) "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." C) "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen." D) "The most common side effects are directly related to the use of anesthesia."
A) "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss."
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make? A) "You said that you feel guilt about your daughter's diagnosis. Let's talk about what is causing you to feel this way." B) "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable." C) "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment." D) "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"
A) "You said that you feel guilt about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
A nurse is providing medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching? A) "You should change positions slowly while taking this medication." B) "This medication is prescribed to help overcome alcohol addiction." C) "You should omit foods containing oxalates while taking phenelzine." D) "You should avoid drinking liquids after your evening meal."
A) "You should change positions slowly while taking this medication."
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom? A) Affective flattening B) Bizarre behavior C) Illogicality D) Somatic delusions
A) Affective flattening
A nurse is caring for a client 2 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 actions should the nurse take? A) Ask the client if she has a plan to commit suicide B) Recognize the attempt at manipulation and escort the client back to her activity C) Assist the client to her room and allow her to rest before resuming the activity D) Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone
A) Ask the client if she has a plan to commit suicide
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? A) Assist the client to the correct room B) Place the client in restraints C) Reorient the client to time and place D) Move the client to a room at the end of the hall
A) Assist the client to the correct room
A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions should the nurse implement to promote relaxation? A) Assisting the client in practicing meditation B) Recognize the client's spiritual preferences C) Encourage the client to identify his positive qualities D) Help the client to identify his previous accomplishments
A) Assisting the client in practicing meditation
A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client? A) Diazepam B) Acamprosate C) Naltrexone D) Disulfiram
A) Diazepam
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (SATA) 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
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? A) Dysrhythmias B) Cataracts C) Pancreatitis D) Bleeding
A) Dysrhythmias
A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol? A) Extrapyramidal symptoms B) Fever C) Intractable hiccups D) Excessive salivation
A) Extrapyramidal symptoms
A nurse is preparing to administer the monthly injection of haloperidol decanoate to a client who has schizophrenia. Which of the following actions should the nurse plan to take? A) Have the client lie down for 30 min after the medication is injected B) Monitor the client for bradycardia following the injection C) Assess the client for a sudden relapse of manifestations D) Administer the medication using a tuberculin syringe
A) Have the client lie down for 30 min after the medication is injected
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (SATA) A) Irritability B) Euphoria C) Insomnia D) Low self-esteem E) Chronic pain
A) Irritability C) Insomnia D) Low self-esteem E) Chronic pain
A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (SATA) A) Muscle spasms of the neck B) Fidgeting behavior C) Blurred vision D) Tremors of the hands E) Sexual dysfunction
A) Muscle spasms of the neck B) Fidgeting behavior D) Tremors of the hands
A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (SATA) A) Paroxetine B) Lithium C) Donepezil D) Valproate E) Carbamazepine
A) Paroxetine B) Lithium D) Valproate E) Carbamazepine
A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of the following clients should the nurse suggest offering the therapy to? A) Post-Traumatic Stress Disorder B) Schizophrenia C) Pedophilia D) Paranoid Personality Disorder
A) Post-Traumatic Stress Disorder
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect? A) Significant change in weight B) Hyperexcitability C) Exaggerated response to stimuli D) Attention seeking behavior
A) Significant change in weight
A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements? A) Sodium B) Potassium C) Vitamin K D) Vitamin C
A) Sodium
A client is admitted with post-traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism? A) The client begins reading a book when he experiences hand tremors in response to loud noise B) The client makes a decision to postpone a needed surgery C) The client focuses on discussing his daily routine when asked about the fire D) The client develops stomach pain when fire is seen on television
A) The client begins reading a book when he experiences hand tremors in response to loud noise
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A) The client runs 4 miles outdoors every afternoon B) The client drinks 2 liters of liquids daily C) The client eats 2 to 3 gm of sodium-containing foods daily D) The client eats foods high in tyramine
A) The client runs 4 miles outdoors every afternoon
A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed? A) Thyroid hormone assay B) Liver function tests C) Erythrocyte sedimentation rate D) Brain natriuretic peptide
A) Thyroid hormone assay
A nurse is reviewing the medical record of a client who has schizophrenia and is receiving olanzapine. Which of the following findings should the nurse identify as an adverse effect of olanzapine? A) Weight gain of 3 lb in 2 weeks B) Delusions of grandeur C) Heart rate 60/min D) Oral candidiasis
A) Weight gain of 3 lb in 2 weeks
A nurse is caring for a client who has schizophrenia and tells the nurse, "they lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make? A) "You are mistaken. Nobody is lying about you or trying to poison you." B) "You seem to be having very frightening thoughts." C) "Why do you think you are being lied about and poisoned?" D) "Who is lying about you and trying to poison you?"
B) "You seem to be having very frightening thoughts."
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A) A client wants to know the current time while there is a clock on the wall B) A client attempts to climb out of bed and repeatedly states she must get home C) A client requests extra blankets when the thermostat in the room indicates 25.6C (78F) D) A client refuses to get out of bed and has no motivation to attend to daily hygiene
B) A client attempts to climb out of bed and repeatedly states she must get home
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been takin glithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? A) Prepare for gastric lavage due to an extremely elevated lithium level B) Administer the morning dose of lithium C) Check the client's medication record to assess whether the client has been refusing her lithium D) Hold the medication and assess for early manifestations of toxicity
B) Administer the morning dose of lithium
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take? A) Praise the client for looking at herself in a mirror B) Ask the client to agree to talk to a nurse whenever she feels the urge to exercise C) Reprimand the client about the potential damage that has occurred due to overexercising her body D) Restrict the client from being weighed
B) Ask the client to agree to talk to a nurse whenever she feels the urge to exercise
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (SATA) A) Short attention span B) Delayed language development C) Spinning a toy repetitively D) Ritualistic behavior E) Consistent limit testing
B) Delayed language development C) Spinning a toy repetitively D) Ritualistic behavior
A nurse is caring for a client who has paraplegia following a diving accident. Which of the following findings indicates that the client is developing depression? A) Flight of ideas B) Difficulty concentrating C) Palpitations D) Paranoia
B) Difficulty concentrating
A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (SATA) A) Inability to find commonly used items B) Inability to perform common tasks C) Difficulty with talking or reading D) Difficulty remembering how to swallow E) Inability to recognize family members
B) Inability to perform common tasks C) Difficulty with talking or reading
A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take? A) Place the client in seclusion if visual hallucinations are present B) Limit the number of questions asked during assessments C) Use frequent touch to provide client support D) Directly tell the client that delusions are not real
B) Limit the number of questions asked during assessments
A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring? A) Tardive dyskinesia B) Neuroleptic malignant syndrome C) Acute dystonia D) Pseudoparkinsonism
B) Neuroleptic malignant syndrome
A nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feelings of survivor guilt, and difficulty concentrating. Which of the following diagnoses describe the client's symptoms? A) Generalized Anxiety Disorder B) Post-Traumatic Stress Syndrome C) Histrionic Personality Disorder D) Dissociative Identity Syndrome
B) Post-Traumatic Stress Syndrome
A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion? A) Active psychiatric disorder B) Previous suicide attempt C) Loss of a parent D) History of substance abuse
B) Previous suicide attempt
A nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an antipsychotic medication. The provider and nursing staff suspect the client is not adhering to his medication therapy. Which of the following interventions should the staff use to encourage the client's adherence? (SATA) A) Perform mouth checks following the administration of the medication B) Provide for once-daily dosing C) Use sustained-release forms D) Engage the client in conversation following medication administration E) Rotate staff that administer the medications
B) Provide for once-daily dosing C) Use sustained-release forms D) Engage the client in conversation following medication administration
A nurse in an urgent care clinic is studying the developmental stages of various clients. In which of the following clients should the nurse expect to see manifestations of autism? A) Neonate B) Toddler C) Middle age D) Geriatric
B) Toddler
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client? A) Watching a video with a group in the day room B) Walking with the nurse in the courtyard C) Participating in a basketball game in the gym D) Joining a group discussion about a local election
B) Walking with the nurse in the courtyard
A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate? A) "This is where you live now." B) "This is a safer place for you to live." C) "Tell me what you like to cook for dinner." D) "Your family said there is no one to care for you at home."
C) "Tell me what you like to cook for dinner."
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. 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."
A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching? A) "Dementia is characterized by a sudden onset of confusion." B) "An altered level of consciousness is associated with dementia." C) "The signs of dementia are progressive and irreversible." D) "Dementia can be triggered by a high fever or dehydration."
C) "The signs of dementia are progressive and irreversible."
A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurses is appropriate? A) "You need to tell the voices to leave you alone." B) "You need to understand that there are no voices." C) "What are the voices telling you to do?" D) "Why do you think you are hearing the voices?"
C) "What are the voices telling you to do?"
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make? A) "You should be aware that excessive sleeping is an early sign of relapse." B) "Relapse is an indication that you are not taking your medications properly." C) "You should keep your provider's and therapist's number with you." D) "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
C) "You should keep your provider's and therapist's number with you."
A nurse is reviewing the medical histories of four clients. Which of the following clients may develop extrapyramidal symptoms from medication therapy? A) A client who is in the third trimester of pregnancy and taking iron supplements B) An older adult client who has pancreatitis and is taking enzymes C) A client who has schizophrenia and it taking antipsychotic medication D) An adult client who has type 2 diabetes mellitus and is taking insulin
C) A client who has schizophrenia and it taking antipsychotic medication
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (SATA) A) Delusions B) Hallucinations C) Anhedonia D) Poor judgement E) Blunt affect
C) Anhedonia E) Blunt affect
A nurse is providing dietary teaching for a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). When the client develops a sample lunch menu, which of the following items requires intervention by the nurse? A) Glass of whole milk B) Celery sticks C) Bologna sandwich D) Sliced apples
C) Bologna sandwich
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? A) Visual hallucination B) Gustatory hallucination C) Command hallucination D) Tactile hallucination
C) Command hallucination
The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? A) He is hard of hearing B) Pain C) Confusion D) Language barrier
C) Confusion
A nurse is planning care for a client who has a prescription for alprazolam. For which of the following adverse effects should the nurse plan to monitor? A) Decreased urine output B) Manifestations of seizure activity C) Inability to recall events D) Increase in white blood cell count
C) Inability to recall events
A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority? A) Reviewing the client's toxicology laboratory report B) Making a contract with the client for eating behavior C) Initiating suicide precautions D) Administering the Hamilton Depression Scale
C) Initiating suicide precautions
A nurse is assessing a client who has schizophrenia. Which of the following behaviors should the nurse anticipate? A) Periods of elation with unusual talkativeness B) Preoccupied with folding clothes C) Invents words that have no meaning D) Recurrent thoughts of past trauma
C) Invents words that have no meaning
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication? A) Thyroid function tests should be performed every 6 months B) A pretreatment electroencephalogram (EEG) will be done C) Liver function tests must be monitored D) High serum sodium levels can cause toxic levels of valproate
C) Liver function tests must be monitored
A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client A) Displays compulsive and ritualistic behaviors B) Reminisces about the past C) Makes up stories when he is unable to remember actual events D) Refuses to leave home to see a provider
C) Makes up stories when he is unable to remember actual events
A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of depressive state. Which of the following interventions is appropriate to include in the plan of care? A) Encourage family to take the client out of the facility for short periods of time B) Reward the client for her change in behavior C) Monitor the client's whereabouts at all times D) Ask the client why her behavior has changed
C) Monitor the client's whereabouts at all times
A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity? A) Constipation B) Urinary retention C) Muscle weakness D) Hyperactivity
C) Muscle weakness
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors? A) Isolate the client for a period of time B) Confront the client about the senseless nature of the repetitive behaviors C) Plan the client's schedule to allow time for rituals D) Set strict limits on the behaviors so that the client can conform to the unit rules and schedules
C) Plan the client's schedule to allow time for rituals
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania? A) The client's spouse reports that client has recently gained weight B) The client is dressed in all black C) The client responds to questions with disorganized speech D) The client reports that voices are telling him to write a novel
C) The client responds to questions with disorganized speech
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!" Which of the following replies by the nurse requires intervention? A) "It sounds frightening to feel like both God and the devil at the same time." B) "I don't understand. Can you tell me what that means?" C) "Are you saying that you are both good and bad?" D) "There is no gate for me to open."
D) "There is no gate for me to open."
A nurse is caring for a client who has a major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? A) "You have a great deal to live for." B) "It's not unusual for depressed people to feel that way." C) "Why do you feel you are worthless?" D) "You've been feeling that your life has no meaning."
D) "You've been feeling that your life has no meaning."
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority? A) Lock the doors to the unit and secure windows so they cannot be opened B) Provide the client with plastic eating utensils for meals C) Remove any objects from the client's environment that could be used for self-harm D) Assign a staff member to stay with the client at all times
D) Assign a staff member to stay with the client at all times
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following? A) Limit the amount of time available to interact with others B) Focus attention on meaningful tasks C) Manipulate and control others' behaviors D) Decrease anxiety to a tolerable level
D) Decrease anxiety to a tolerable level
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A) Increased vital capacity B) Moist skin C) Heat intolerance D) Decreased mental status
D) Decreased mental status
A nurse is planning to administer haloperidol to a client who has acute psychosis. The nurse should monitor the client for which of the following findings as an adverse effect of the medication? A) Excess salivation B) Increased agitation C) Diarrhea D) Dystonia
D) Dystonia
A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care? A) Allow for adjustment of rules to correlate with the child's behavior B) Provide a flexible schedule that adjusts to the child's interests C) Allow for imaginative play with peers without supervision D) Establish a reward system for positive behavior
D) Establish a reward system for positive behavior
A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to tule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions? A) Pancreatitis B) Cholecystitis C) Tuberculosis D) Hypothyroidism
D) Hypothyroidism
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first? A) Call for assistance to place the client in restraints B) Escort the client to an unlocked seclusion room C) Offer the client a PRN antianxiety medication D) Speak to the client calmly, giving simple directions
D) Speak to the client calmly, giving simple directions
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A) Rotate assignment of daily caregivers B) Provide an activity schedule that changes from day to day C) Limit time for the client to perform activities D) Talk the client through tasks one step at a time
D) Talk the client through tasks one step at a time
A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam? A) The client states, "I see purple bugs crawling on the wall." B) The client tells the nurse that he is too tired to attend the group meeting C) The client tells the nurse he is a government agent D) The client states, "my heart is pounding out of my chest."
D) The client states, "my heart is pounding out of my chest."
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? A) Rapid speech B) Chills C) Distorted perceptual field D) Urinary frequency
D) Urinary frequency
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take? A) Instruct the client to sit down and stop pacing B) Allow the client to pace alone until physically tired C) Have a staff member escort the client to her room D) Walk with the client at a gradually slower pace
D) Walk with the client at a gradually slower pace