NUR 384 Exam 1

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? Select all that apply. A. Voice changes B. Seizure activity C. Disorientation D. Cough E. Neck pain

A. Voice changes D. Cough E. Neck pain

A charge nurse is discussing rTMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "RTMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following rTMS." C. "RTMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for rTMS treatments 3 to 5 times a week for the first several weeks."

D. "I will schedule the client for rTMS treatments 3 to 5 times a week for the first several weeks." When evaluating a client's understanding for rTMS, the following information indications an understanding of the procedure by the client. RTMS is commonly prescribed 3 to 5 times a week for the first four to six weeks. RTMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment.

A nurse is reviewing the medical records of a group of clients. The nurse should identify that which of the following factors places a client at risk for mental illness? a. A family member with a diagnosis of diabetes b. A medical diagnosis of diabetes c. A history of using community support services d. A History of abuse

d. A History of abuse A history of abuse places a client at risk for mental illness.

A nurse in a mental health facility is caring for a client. Who asks, " why can't you be my therapist?" Which of the following therapeutic responses should the nurse give? 1. "I am glad you are comfortable talking with me, but your therapy is most beneficial from a therapist with additional training to best guide and talk with you." 2. "That is not part of my current role. I work more with ensuring you take you medications." 3. "The therapist is the only person who can conduct the therapy session while in the facility." 4. "Therapy must be conducted by a licensed therapist. I do not understand the techniques they do with you."

1. "I am glad you are comfortable talking with me, but your therapy is most beneficial from a therapist with additional training to best guide and talk with you." Often, the nurse will not be performing the therapy. Instead, the nurse might be collecting initial data, recognizing the client's need for therapy, or even advocating for the client's right to treatment.

A nurse is talking with a new client to who is at risk for suicide following their partner's death. Which of the following statements by the nurse explains the purpose of milieu therapy? A. "Milieu therapy is focused on creating a safe, healing, therapeutic environment." B. "Milieu therapy is the scheduled activities focused on improved client socialization." C. "Milieu therapy consists of scheduled group sessions addressing common mental health needs." D. "Milieu therapy is primary focus is on client education based on individual treatment goals."

A. "Milieu therapy is focused on creating a safe, healing, therapeutic environment."

A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

C. Subgroup A subgroup is a small number of people within a larger group who function separately from that group.

A nurse is explaining to a client who has a mental illness why mental health promotion is important. The nurse should inform the client that mental health promotion has a wide variety of benefits, including which of the following? 1. "Mental health promotion promotes positive mental health, which in turns helps prevent you from missing work due to mental illness." 2. "Mental health promotion can assist you in getting off of your medication." 3. "Mental health promotion guides you to a variety of therapies to treat your mental illness." 4. "Mental health promotion increases the chances of you having to be hospitalized every time your mental illness symptoms manifest."

1. "Mental health promotion promotes positive mental health, which in turns helps prevent you from missing work due to mental illness." Mental illness can cause a client to miss work. By promoting mental health, the client is less likely to miss work due to mental illness.

A nurse is teaching a newly licensed nurse about psychodynamic theory. Which of the following should the nurse include as an example related to this theory? 1. A client who reports being afraid of storms because they experienced a tornado as a child 2. A client who reports they recently fractured their leg in a car accident 3. A client who was an active military member for 10 years and engaged in combat 4. A client who is currently going through a divorce and is struggling to accept the loss of their marriage

1. A client who reports being afraid of storms because they experienced a tornado as a child The nurse should include this as an example because the psychodynamic theory is based on Freud's psychoanalytic theory that human behavior is influenced by childhood experiences.

A nurse is caring for an adolescent, who has an adverse childhood experience and was admitted to the inpatient unit with behavioral problems. The nurse should anticipate the provider prescribing which of the following types of treatment. 1. Cognitive therapy 2. Seclusion 3. Electroconvulsive therapy (ECT) 4. Restraints

1. Cognitive therapy Cognitive therapy can examine the adolescent's past experiences and how it is impacting their current behaviors. This therapy can be used with both adolescents and children, and it assists in helping them understand current behaviors and responses.

A nurse is assisting a client and getting ready to have their first telehealth appointment with her therapist. Which of the following actions should the nurse take to assist the client with this type of therapy? 1. Ensure the client's computer is connected to the internet. 2. Make sure the client has no one else in the room during their appointment. 3. Verify the client's history and medication list. 4. Have the client come to the clinic to meet the therapist before the initial appointment.

1. Ensure the client's computer is connected to the internet. To assist the client in setting up telehealth services, the nurse should ensure the client's computer or electronic device is connected to the internet. If the client cannot virtually connect from home, they are unable to attend their appointment.

A nurse in a newly licensed nurse in a mental health facility are discussing their roles related to therapy. Which of the following interventions should the nurse discuss with the newly licensed nurse? 1. Ensuring a therapeutic nurse-client relationship with those on the unit 2. Leading family group therapy sessions 3. Giving clients medications before each therapy session 4. Instructing the clients to select which types of therapy they would like to use

1. Ensuring a therapeutic nurse-client relationship with those on the unit The nurse should discuss ensuring a therapeutic nurse-client relationship with clients on the unit because it builds trust with the clients and promotes their wellbeing.

A nurse is preparing an in-service for nursing staff on the concept of holistic nursing. Which of the following components should the nurse include in the teaching? 1. Holistic nursing considers the client's emotional health 2. Holistic nursing care is limited to spiritual health practices 3. Practicing holistic nursing requires certification beyond nursing licensure 4. Assessment of holistic client practices is limited to outpatient settings

1. Holistic nursing considers the client's emotional health Holistic nursing care considers the client's physical, emotional, social, spiritual, and intellectual health.

A nurse is observing a group of children interacting. The nurse notes anytime a question is asked, all the children want to answer, and will often talk over each other. Then there should recognize that this behavioral is indicative of which of the following stages of coal breaks theory. 1. Instrumental relativity orientation 2. Postconvention 3. Conventional 4. Preconventional

1. Instrumental relativity orientation In stage two, instrumental relativity orientation, behaviors are guided by a concern for self and wanting to satisfy an individual's own needs, with others' needs being a secondary consideration.

A nurse is planning to teach a client about behavioral therapy which of the following statements are the nurse plan to include? 1. "Behavioral therapy is based on the belief that problems are rooted in a person's past." 2. "Behavioral therapy is a type of psychotherapy that helps you modify your maladaptive behavioral patterns." 3. "Behavioral therapy holds that the unconscious mind influences your thoughts and feelings." 4. "Behavioral therapy is working one-on-one with a therapist through talk therapy."

2. "Behavioral therapy is a type of psychotherapy that helps you modify your maladaptive behavioral patterns." Behavioral therapy is a type of psychotherapy that focuses on modifying a client's maladaptive behaviors, patterns, and responses, instead of using adaptative behaviors. The therapy follows the concept that behaviors are learned and can have negative consequences.

A nurse is reviewing the concept of bias with a newly licensed nurse. Which of the following scenarios should the nurse use to demonstrate biased treatment? 1. A client is not permitted to attend the group therapy activity due to wanting to harm another peer in the group. 2. A client is not permitted to attend the group therapy activity because they practice the Buddhist faith. 3. A client is not permitted to attend the group therapy activity due to having a family therapy session during the same time. 4. A client is not permitted to attend the group therapy activity due to having thoughts of harming themselves with "anything they can find."

2. A client is not permitted to attend the group therapy activity because they practice the Buddhist faith. Bias is when treatment of a client is verified in the form of stereotyping, prejudice, or discrimination. Therefore, this scenario demonstrates biased treatment.

A nurse is planning care for a group of clients. Which of the following clients would benefit from cognitive behavioral therapy (CBT) ? 1. A client who has an intellectual development disability 2. A client who has Tourette's syndrome 3. A client who has dementia 4. A client who has insomnia

2. A client who has Tourette's syndrome CBT is a form of therapy that is effective for a variety of mental illnesses, including depression, anxiety, and eating disorders. It assists clients in adapting and changing their thinking patterns. Tourette's syndrome is a nervous system disorder with tics, and CBT can be used to assist the person in adapting to functioning with tics.

A nurse is reviewing humanistic theories. Which of the following Sirus were primarily involved in developing the humanistic theory? 1. Sigmund Freud 2. Abraham Maslow 3. Erik Erikson 4. John Watson

2. Abraham Maslow The humanistic theory is based on humanism. Abraham Maslow contributed to the concept of this theory.

A nurse is caring for an older adult client who has major depressive disorder. The client states, I don't think I am financially prepared for retirement, yet I am eligible to retire this year. The nurse should identify that the client is in which of the following stages of Erikson stages of development? 1. Transcendence 2. Ego integrity vs. despair 3. Generativity vs. stagnation or self-absorption 4. Intimacy vs. isolation

2. Ego integrity vs. despair The client is currently in this stage of development. Life experiences provide a sense of dignity. Life goals have been completed and death is not feared. Failure to meet these stages results in disappointment in how the person's life has gone.

A nurse is explaining to a newly hired nurse how mental help promotion can be used for clients. Which of the following examples should the nurse use in the explanation? Select all that apply. 1. Administering client medications on an inpatient unit 2. Following suicide precautions for a client 3. Allowing a client to skip individual therapy if they are tired 4. Assisting the client in using adaptive coping skills 5. Allowing the client to use exercise equipment when becoming anxious in group therapy

2. Following suicide precautions for a client 4. Assisting the client in using adaptive coping skills 5. Allowing the client to use exercise equipment when becoming anxious in group therapy

A nurse is discussing the different forms of complementary and alternative therapy with another nurse. Which of the following treatment should be considered on this list? Select all that apply. 1. Individual therapy 2. Pet therapy 3. Meditation 4. Yoga 5. Group therapy

2. Pet therapy 3. Meditation 4. Yoga

A newly licensed nurse asked a charge nurse, what is the difference between a suicide attempt and self harm? Which of the following responses should I charge nurse give? 1. "When a client attempts suicide, they do so in a manner by causing self-harm." 2. "The two terms are the same and can be used interchangeably." 3. "A suicide attempt is when a person harms themselves with the intent to die but does not. Self-harm is when a client intentionally inflicts harm on themselves but does not have intention to kill themselves." 4. "A suicide attempt is the manner in which someone kills themselves. Self-harm is just the person acting out."

3. "A suicide attempt is when a person harms themselves with the intent to die but does not. Self-harm is when a client intentionally inflicts harm on themselves but does not have intention to kill themselves." A suicide attempt is when a person harms themselves with the intent to die, but a person who self-harms has no intention of killing themselves.

A nurse is planning to add a client to an established therapy group on the unit. The group currently includes a 13-year-old adolescent, who has depression, a 15 adolescent who has a history of self harm, and a 14 year old adolescent, who recently threaten to kill themselves. Which of the following adolescent should the nurse add to this group? 1. A 16-year-old adolescent who has schizophrenia 2. A 17-year-old adolescent who has a substance use disorder 3. A 12-year-old adolescent who has anxiety and depression 4. A 14-year-old adolescent who has borderline personality disorder

3. A 12-year-old adolescent who has anxiety and depression Group therapy is a psychosocial therapy in which multiple clients meet with a therapist. In this setting, ideas and insights are shared for the purpose of assisting in improving one's coping skills. This client would fit in with a group of adolescents managing depression and self-harm.

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide. 1. A client who states that they are stopping their medication 2. A client who states they have been sleeping 12 hr a day 3. A client who is giving away their possessions 4. A client requests an appointment to discuss their depression

3. A client who is giving away their possessions When a client begins to give away their possessions, it can be a warning sign that they are planning to kill themselves. The nurse should further explore the client's behaviors and symptoms.

A nurse is reinforcing teaching with a client about the purpose of psychoanalytic therapy. Which of the following statements should the nurse include in the teaching? 1. "Psychoanalytic therapy helps you see yourself as an individual and learn adaptive coping skills." 2. "Psychoanalytic therapy is a chance for you to meet with others and discuss similar diagnoses." 3. "Psychoanalytic therapy is aimed at helping you meet your family needs." 4. "Psychoanalytic therapy allows you to complete your therapy from home once you are discharged."

4. "Psychoanalytic therapy allows you to complete your therapy from home once you are discharged." The purpose of psychoanalytic therapy is to help the client be able to learn adaptive coping skills. Psychoanalytic therapy is conducted by examining the unconscious mind and how it influences a person's thoughts, feelings, and behaviors.

A nurse is teaching another nurse about Freud's psychoanalytic theory related to human behavior. Which of the following statements regarding the id should the nurse include in the teaching? 1. "The id is the rational part of a person's personality." 2. "The id is the part that guides a person's morals or why they follow rules." 3. The id helps teach clients what is right versus wrong regarding their behavior." 4. "The id is often an area that is used for instant gratification."

4. "The id is often an area that is used for instant gratification." The first part of one's personality is the id, known for instant gratification. This can include gratification of physical needs or desires.

A nurse is teaching a client about therapy. Which of the following statements should the nurse include? 1. "You can refuse therapy. We are just required to offer it to you." 2. "You can select to do therapy, but this must be decided on admission." 3. "Your provider requires you to attend therapy in both an individual and group setting while on the unit." 4. "Therapy can be used in conjunction with your medications to improve your health."

4. "Therapy can be used in conjunction with your medications to improve your health." Informing the client of the variety of therapies is often geared toward describing to the client what the therapy is. The nurse can instruct the client on the benefits of the different types of therapies and what types of diagnoses the therapies can assist with.

A nurse is reviewing the physical environment of a child inpatient unit. Which of the following contraindicates Milieu therapy? 1. A seclusion room with nothing in it 2. A quiet room with music and warm lighting 3. An exercise room with bikes and treadmills 4. A craft room with scissors and other art supplies

4. A craft room with scissors and other art supplies A craft room with scissors could be a safety risk and does not prevent self-destructive behaviors, which is a contradiction of milieu therapy.

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? Select all that apply. A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents."

A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence."

A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy

A. Aversion therapy The nurse should identify that aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior and is used for a client who has a new prescription for disulfiram for treatment of alcohol use disorder.

A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries

A. Discussing ways to use new behaviors When generating solutions, the nurse should discuss ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase.

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? Select all that apply. A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy

A. Educational groups B. Medication dispensing programs C. Individual counseling programs E. Family therapy

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion? A. Excessive stressors cause the client to experience distress. B. The body's initial adaptive response to stress is denial. C. Absence of stressors results in homeostasis. D. Negative, rather than positive, stressors produce a biological response.

A. Excessive stressors cause the client to experience distress. When taking action and preparing an educational seminar on stress for other nursing staff, the nurse should discuss distress is the result of excessive or damaging stressors (anxiety or anger).

A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information

A. Offering advice Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends to interfere with the client's ability to make personal decisions and choices.

A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? Select all that apply. A. Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

A. Priority restructuring B. Monitoring thoughts D. Journal keeping

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? Select all that apply. A. "Client ate most of their breakfast." B. "Client was offered 8 oz of water every hr."​​​​​​​ C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

B. "Client was offered 8 oz of water every hr."​​​​​​​ C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000."

A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."

B. "The therapist will focus on my past relationships during our sessions." When evaluating a form of therapy for anxiety disorder, the nurse should identify that classical psychoanalysis is a therapeutic process that requires many sessions over months to years and places a common focus on past relationships to identify the cause of the anxiety disorder.

A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months

B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia An ACT group works with clients who are nonadherent with traditional therapy (the client in a home setting who keeps "forgetting" a scheduled injection).

A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? Select all that apply. A. Encourage the group to work toward goals. B. Define the purpose of the group. C. Discuss termination of the group. D. Identify informal roles of members within the group. E. Establish an expectation of confidentiality within the group.

B. Define the purpose of the group. C. Discuss termination of the group. E. Establish an expectation of confidentiality within the group.

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation Submit

B. Denial When assessing the client, the nurse should identify this is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? Select all that apply. A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

B. Depressed immune system C. Increased blood pressure E. Unhappiness

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? Select all that apply. A. Reassure the client that everything will be okay. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed-ended questions.

B. Discuss prior use of coping mechanisms with the client. D. Demonstrate a calm manner while using simple and clear directions.

A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I might begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."

D. "I should say the first thing that comes to my mind." When taking action, the nurse should identify that free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind.

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

B. False imprisonment

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services. B. Identify the client's perception of their mental health status. C. Include the client's family in the interview. D. Teach the client about their current mental health disorder.

B. Identify the client's perception of their mental health status. The first action the nurse should take when using the nursing process is assessment, identifying the client's perception of their mental health status provides important information about the client's psychosocial history.

A nurse is conducting a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

B. Manipulation The nurse should identify, manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda.

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate of 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

B. Moderate When analyzing data, the nurse should identify that moderate anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious.

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. ​​​​Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.​​​​​​​

B. Tell the nurse to stop discussing the behavior. The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. The first action to take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location.

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with them. I love them, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness. B. Use assertiveness techniques. C. Exercise regularly. D. Rely on the support of a close friend.

B. Use assertiveness techniques. When taking actions and recommending means to promote change in a client's situation the nurse should recommend, assertive communication allows the client to assert their feelings and then make a change in the situation.

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to themselves

C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod When analyzing cues the nurse should identify a client who is a current danger to self or others is a candidate for a temporary emergency admission.

A nurse is planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse visit first? A. A client who received a burn on the arm while using a hot iron at home B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

C. A client who reports hearing a voice saying that life is not worth living anymore A client who hears a voice saying life is not worth living anymore is at greatest risk for self-harm, and the nurse should visit this client first.

A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? Select all that apply. A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. All encounters are goal-directed. D. Positive behavior changes are encouraged. E. Promotes balance of client autonomy and safety.

C. All encounters are goal-directed. D. Positive behavior changes are encouraged. E. Promotes balance of client autonomy and safety.

A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions? A. Observes group techniques without interfering with the group process B. Discusses a technique and then directs members to practice the technique C. Asks for group suggestions of techniques and then supports discussion D. Suggests techniques and asks group members to reflect on their use

C. Asks for group suggestions of techniques and then supports discussion

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide. B. Having a weekly visit from a nurse case worker. C. Attending a partial hospitalization program. D. Visiting a community mental health center on a daily basis.

C. Attending a partial hospitalization program. When taking action, the nurse should suggest the following strategies for follow-up care for a client who has a severe mental illness and requires supervision, a partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present.

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

C. Bipolar disorder with rapid cycling When taking action and discussing indications for ECT with a peer group, the nurse should include the following information: ECT is indicated for the treatment of bipolar disorder with rapid cycling.

A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression

C. Establishing rehabilitation programs to decrease the effects of depression Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness. Educating and providing support for risks is considered a primary prevention intervention.

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? Select all that apply. A. Hypotension B. Paralytic ileus C. Memory loss D. Polyuria E. Confusion

C. Memory loss E. Confusion

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I should receive ECT once a week for 6 weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

D. "I will receive a muscle relaxant to protect me from injury during ECT." When evaluating a client's understanding of ECT, the following information indications an understanding of the procedure by the client. A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity.

A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space​​​​​​​ B. Posture C. Eye contact D. Intonation

D. Intonation When recognizing cues, the nurse should identify that intonation is a component of verbal communication.

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications.

D. Monitor the client for adverse effects of medications.

A nurse in a mental health practitioner's office is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

D. Restating The nurse is using the therapeutic communication technique of restating which allows the nurse to repeat the main idea expressed by the client.

A nurse is educating a newly licensed nurse about manifestations of alcohol withdrawal. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "An increase in the release of the neurotransmitter glutamate causes an elevated heart rate." b. "A decrease in the release of the neurotransmitter dopamine causes a sense of euphoria." c. "An increase in the release of the neurotransmitter serotonin causes muscle aches." d. "A decrease in the release of the neurotransmitter norepinephrine causes nausea."

a. "An increase in the release of the neurotransmitter glutamate causes an elevated heart rate." The nurse should identify that in alcohol withdrawal, large amounts of glutamate release, causing CNS excitation, which leads to an increase in heart rate and blood pressure.

A nurse is explaining what "duty to warn" means to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding? a. "If a client threatens to harm another person, health care providers have a responsibility to inform that person." b. "If a client threatens to harm themselves, there is a responsibility to report that client to their family." c. "If a client threatens to harm themselves, there is a responsibility to tell their medical provider." d. "If a client threatens to harm another person, there is a responsibility to inform the other person's family."

a. "If a client threatens to harm another person, health care providers have a responsibility to inform that person." A health care provider has a "duty to warn" when there is a threat from a client to another person to cause harm to them.

A nurse is discussing ethical principles with another nurse. Which of the following should the nurse include as an examples of the principle of nonmaleficence? a. A nurse evaluates the clint's desire for autonomy while considering the personal safety of other clients on the unit b. A nurse encourages the client to determine which therapeutic activity they would like to participate in c. A nurse plans to spend equal amounts of time with each client assigned to their care d. A nurse makes a referral to speech therapy for a client who is experiencing dysphagia

a. A nurse evaluates the clint's desire for autonomy while considering the personal safety of other clients on the unit The principle of nonmaleficence involves doing no harm. By weighing the risks and benefits of the client's desire for autonomy while considering the safety of the other clients on the unit, the nurse is practicing nonmaleficence.

A nurse is caring for a client who is experiencing diaphoresis, palpitations, and a sense of impending doom. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepine b. Dopamine antagonist c. Selective serotonin reuptake inhibitor d. Mood stabilizer

a. Benzodiazepine The nurse should identify that benzodiazepines are used to treat acute anxiety by regulating the function of the neurotransmitter gamma-aminobutyric acid (GABA).

A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. When assessing the client, which of the following purposes describes the function of the CIWA-Ar scale? a. Determine the client's severity of alcohol withdrawal and adjust care accordingly b. Determine the client's risk of developing severe manifestations c. Identify genetic factors that influence alcohol withdrawal d. Analyze and interpret lab and medical imaging data

a. Determine the client's severity of alcohol withdrawal and adjust care accordingly The nurse should identify that the CIWA-Ar scale provides guidelines for the nurse to follow when rating the severity of manifestations of alcohol withdrawal.

A nurse is caring for a client who has been taking risperidone and reports experiencing muscle spasms in their neck and difficulty opening their mouth. Which of the following medications should the nurse anticipate the provider to prescribe for this client? a. Diphenhydramine b. Valbenazine c. Escitalopram d. Naloxone

a. Diphenhydramine The nurse should anticipate the provider prescribing diphenhydramine for the client. Diphenhydramine is an anticholinergic medication that is effective in treating extrapyramidal symptoms (EPS) of acute dystonia, such as muscle spasms in the neck and difficulty opening the mouth.

A nurse is educating a newly licensed nurse about opiate withdrawal. Which of the following findings should the nurse instruct the newly licensed nurse to monitor for? a. Muscle aches b. Respiratory depression c. Hallucinations d. Increased risk of seizure

a. Muscle aches The nurse should identify that the large amount of norepinephrine present during opiate withdrawal results in findings, such as muscle aches, goose flesh, and pupil dilation.

A nurse is preparing a presentation for high school students about the causes of mental illness. Which of the following should the nurse include in the presentation? a. Stress has been identified as a potential cause of mental illness b. Manifestations of mental illness can be resolved through motivation c. Medications serve as a cure for mental illness d. Psychotherapy can serve as a cure for mental illness

a. Stress has been identified as a potential cause of mental illness The nurse should identify that stress and the immune system's inflammatory response has been determined to be one causative factor for developing mental illnesses.

A nurse is caring for a client who reports that they are having a hard time completing their ADLs due to feeling anxious. The client also reports feeling tired, difficulty sleeping, and having a poor appetite. The nurse should anticipate they would fall in which end of the mental health continuum? a. The client would fall closer towards the mental illness end or struggling b. The client would fall closer towards the mental health end or thriving c. The client would not clearly fall on the mental health continuum as they do not have a mental illness diagnosis d. The client should be evaluated by the provider before their observance on the mental health continuum is noted, as currently they would fall in the middle

a. The client would fall closer towards the mental illness end or struggling The mental health continuum is a range of responses a person displays in response to life events. The ends vary between positive and negative responses, often viewed as mental health versus mental illness.

A nurse is caring for a newly admitted client who states they are concerned about their privacy and rights while on the psychiatric unit. The nurse should explain to the client that they have which of the following rights? a. The right to refuse treatment b. The right for their information to be shared with their family at any time c. The right for their clinical notes to be shared with anyone at the facility d. The right for providers to solely decide their treatment options

a. The right to refuse treatment The right to self-determination allows a client to refuse treatment, including medications. Medication refusals for mental illness are often due to side effects of the stigma of taking such a medication.

A nurse is providing education to the partner of a client who exhibits poor muscle function, poor memory, and poor concentration. Which of the following statements should the nurse make when explaining the client's findings to the partner? a. "Glutamate interacts with GABA in the brain, causing an individual to experience manifestations of poor motor movements." b. "A dysfunction in acetylcholine receptors may be a cause for motor movement dysfunction." c. "Norepinephrine is a neurotransmitter that is primarily responsible for muscle movement." d. "Recreational drugs that block histamine receptors cause manifestations of psychosis."

b. "A dysfunction in acetylcholine receptors may be a cause for motor movement dysfunction." The nurse should identify that acetylcholine regulates the sleep-wake cycle and is a primary neurotransmitter for muscle functioning.

A nurse is educating a newly licensed nurse about the purpose of neurotransmitters. Which of the following statements by the newly licensed nurse indicates understanding of the education? a. "Dopamine is responsible for inhibiting behaviors caused by stress." b. "Serotonin is responsible for regulating sleep and body temperature." c. "Norepinephrine is primarily responsible for symptom presentations related to schizophrenia." d. Histamine is an excitatory neurotransmitter that is responsible for pain management and pleasure."

b. "Serotonin is responsible for regulating sleep and body temperature." Serotonin is an inhibitory neurotransmitter that is responsible for emotional regulations, sexual behaviors, temperature regulation, sleep, and pain management.

A nurse is discussing the DSM-5 TR with a newly licensed practical nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the DSM-5? a. "I would use the DSM-5 TR to diagnose clients who have mental health disorders." b. "The DSM-5 TR assists in planning nursing interventions for clients who have a mental health disorder." c. "I would use the DSM-5 TR as a guide instructing what specific criteria or questions should be asked for a suspected mental health diagnosis." d. "The DSM-5 TR tells how to treat a patient who has a mental health diagnosis."

b. "The DSM-5 TR assists in planning nursing interventions for clients who have a mental health disorder." Nurses often use the DSM-5 TR diagnostic information to assist with planning, implementing, and evaluating client care. This information can guide nursing interventions for specific needs.

A nurse is discussing milieu therapy with a group of newly licensed nurses. Which of the following statements should the nurse make? a. Create an environment where structure is promoted over autonomy b. Create an environment that is safe and beneficial for recovery. c. The mental health provider is responsible for structure and maintenance of the therapeutic milieu. d. Ensure spontaneous changes in activities throughout the clients daily schedule

b. Create an environment that is safe and beneficial for recovery. The nurse should create an environment that promotes safety for the client and others and is beneficial for promoting recovery of the client. These elements are the foundation for maintaining a therapeutic milieu.

A nurse is planning a presentation regarding mental illness for a local health fair. Which of the following should the nurse include as a characteristic of mental illness? a. Resilience following a loss of a job b. Difficulty maintaining social relationships c. Volunteering at a crisis center d. Ending a friendship with an individual who demands participation in dangerous activities

b. Difficulty maintaining social relationships Mental illnesses are associated with distress and/or problems functioning in social, work, or family activities.

A nurse in the ED is caring for a client who has acute haloperidol toxicity. Which if the following findings should the nurse identify as consistent with neuroleptic malignant syndrome? a. Dilated pupils and GI discomfort b. Hyperthermia and elevated creatinine kinase c. Respiratory depression and comatose state d. Slumped posture and shuffling gait

b. Hyperthermia and elevated creatinine kinase The nurse should identify that hyperthermia and elevated creatine kinase are findings associated with neuroleptic malignant syndrome.

A nurse is reviewing the serum lithium report for a client who has bipolar disorder. Which of the following manifestations should the nurse expect the client to be experiencing with a lithium level of 2.2 mEq/L? a. Severe respiratory complications b. Jerking motor movements c. GI discomfort d. Abnormal involuntary movements of the tongue

b. Jerking motor movements Jerking motor movements are associated with advanced lithium toxicity at levels of 2.0 to 2.5 mEq/L.

A nurse is preparing a poster presentation on the priorities of Healthy People 2030. Which of the following priority goals should the nurse include? a. The practice of trephination for the treatment of mental illness b. Prevention practices related to cyber-bullying c. Increasing institutionalization of clients who have severe mental health disorders d. Limit screening of mental illness to those individuals who display manifestations

b. Prevention practices related to cyber-bullying Cyber-bullying is a stressor that can result in mental health disorders. By implementing practices targeted at prevention of cyber-bullying, the priority goal of prevention of mental health disorders is met.

A nurse is caring for a client who is prescribed a tricyclic antidepressant medication. Which of the following topics should the nurse prepare to discuss with the client? a. It is important to take the medication first thing in the morning b. Relief of manifestations should not be expected for a few weeks c. There are benefits associated with combining tricyclic antidepressant with St. John's Wort d. Foods that are known to be high in dietary tyramine should be avoided

b. Relief of manifestations should not be expected for a few weeks The nurse should identify that antidepressants typically take a few weeks for a client to notice a relief of manifestations.

A nurse is caring for a client who has mood dysregulation, decreased sex drive, and decreased sleep. Which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations? a. Dopamine b. Serotonin c. Norepinephrine d. Histamine

b. Serotonin The nurse should identify that serotonin is an inhibitory neurotransmitter that is responsible for emotional regulations, sexual behaviors, temperature regulation, sleep, and pain management

A nurse is caring for a client who is prescribed citalopram and is being monitored for activation syndrome. Which of the following findings should the nurse identify as an indicator of activation syndrome? a. High blood pressure b. Suicidal ideations c. Tremors and confusion d. Trouble sleeping and increased anxiety

b. Suicidal ideations The nurse should identify that suicidal ideations are associated with activation syndrome and should be reported to the provider immediately. Activation syndrome includes clinical manifestations of irritability, anxiety, impulsivity, aggressiveness, and agitation.

A nurse is discussing different factors of the determinants of mental health during a staff meeting. Which of the following factors should the nurse include in the discussion? (SATA) a. Receiving paid maternity leave b. Unsafe drinking water c. Exposure to an adverse childhood event d. A playground in the neighborhood e. National policy addressing cyber-bullying

b. Unsafe drinking water c. Exposure to an adverse childhood event d. A playground in the neighborhood e. National policy addressing cyber-bullying

A nurse is educating a group of high school students about mental illness. Which of the following statements should the nurse make about etiology of a mental illness? a. "Schizophrenia can be detected through a complete blood count." b. "It is possible to predict the likelihood of developing manifestations of a mental illness." c. "Developing a mental illness seems to be related to both genetic and environmental factors." d. "Regular physical examinations are commonly used to diagnose mental illness."

c. "Developing a mental illness seems to be related to both genetic and environmental factors." The nurse should identify that the cause of mental illness is largely unknown. Many experts contend that developing a mental illness can be inherited or linked to genetic factors and may be the result of environmental factors, such as stress or trauma.

A nurse is providing education to the family of a client who is experiencing psychosis. Which of the following statements should the nurse make when explaining the role of glutamate in this disorder? a. "Glutamate is an excitatory neurotransmitter that is responsible for learning and memory." b. "Glutamate is essential to sleep and muscle functioning." c. "Glutamate is responsible for affective and cognitive functioning." d. "Glutamate regulates the release of histamine and serotonin."

c. "Glutamate is responsible for affective and cognitive functioning." The nurse should identify that dopamine interacts with glutamate in various areas of the brain to regulate motor, affective, and cognitive functions. High levels of glutamate can serve as a precursor to manifestations of psychosis.

A nurse is providing education to a client about the process of neurotransmission. Which of the following statements about neurotransmission should the nurse make? a. "Neurotransmitters function by storing glucose in vesicles found in neurons." b. "Neurotransmitters are rarely found in the brain." c. "Neurotransmitters are chemical components that allow neurons to communicate with each other." d. "After a neurotransmitter completes neurotransmission, it is then activated by the enzyme transferase."

c. "Neurotransmitters are chemical components that allow neurons to communicate with each other." The nurse should identify that the chemical components the neuron sends and receives are called neurotransmitters.

A nurse is providing teaching to a group of newly licensed nurses about stigma. Which of the following client scenarios should the nurse include as an example of self-stigma? a. A client refuses to go to their provider for manifestations of anxiety until they meet with their cultural leader, a shaman b. A client stops taking their medication for anxiety because they do not like how it makes them feel c. A client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know they are on an antidepressant d. A client refuses a follow-up appointment for their anxiety because they are waiting until they can arrange their transportation

c. A client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know they are on an antidepressant Self-stigma is when an individual has a negative view or internalized shame regarding their mental illness, often due to the public stigma of mental illness.

A nurse is caring for a client who is newly admitted to the acute psychiatric unit for alcohol use disorder. The client reports growing up in an Amish community. Which of the following actions should the nurse take? a. Inform the client that the nurse follows Judaism b. Provide the client with a Bible c. Assess for personal bias related to alcohol use disorder before interacting with the client d. Ask the client where they grew up practicing Amish traditions

c. Assess for personal bias related to alcohol use disorder before interacting with the client To ensure the nurse does not have any bias in their treatment of the client, the nurse should first understand what their own culture and biases are to not hinder client care.

A charge nurse is presenting on the topic of mental health diagnoses during a unit meeting. The charge nurse should identify that the DSM-5 TR classification is used in conjunction or paired with what other classification system? a. Nursing Intervention Classifications b. Maslow's hierarchy of needs c. International Classification of Disease d. Erikson's Stages of Psychosocial Development

c. International Classification of Disease The DSM-5 classification is often used in conjunction or paired with the World Health Organization's International Classification of Disease (ICD).

A nurse is caring for a client who has a diagnosis of bipolar disorder and recently begun lithium therapy. Which of the following manifestations should the nurse identify as indicative of early lithium toxicity? a. Blurred vision and tinnitus b. Muscle jerking and stupor c. Nausea and coarse tremors d. Respiratory distress and a comatose state

c. Nausea and coarse tremors Physiological manifestations of early lithium toxicity include GI discomfort, nausea, coarse tremors, vomiting, and diarrhea.

A nurse is caring for a client who is experiencing disruptions in sleep, appetite, and reports having a depressed mood. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepine b. Dopamine antagonist c. Selective serotonin reuptake inhibitor d. Mood stabilizer

c. Selective serotonin reuptake inhibitor The nurse should identify that selective serotonin reuptake inhibitors are used to manage manifestations of depression, such as loss of pleasure in activities and disruptions in sleep and appetite.

A nurse is working in a neighborhood where the population is culturally diverse. Which of the following actions should the nurse take to ensure the delivery of culturally competent care? a. Reflect on their own culture b. Read a book about the countries of the residents' ancestry c. Talk to the residents of the neighborhood about their culture d. Provide care that meets the resident's needs

c. Talk to the residents of the neighborhood about their culture Cultural competence involves gaining knowledge about another individual's culture. Speaking to the residents of the neighborhood can assist the nurse in gaining this knowledge.

A nurse is presenting information on mental health services over the last 50 years to a group of newly licensed nurses. in 1946, the National Mental Health Act was signed into law which resulted in which of the following? a. The establishment of the mental health court to determines soundness or fitness to stand trial b. The development of mental health centers throughout community settings c. The creation of the National Institute for Mental Health d. The coverage of mental health services for children and youth

c. The creation of the National Institute for Mental Health The National Mental Health Act created the National Institute of Mental Health. The need for psychiatric services has increased over the years, specifically following World War II. The National Mental Health Act was signed in 1946 by President Harry Truman. This called for a National Institute of Mental Health, and the first meeting of the council took place that same year. The National Institute of Mental Health is a federal agency that researches mental illness and was a pioneer in assisting in the transformation of treatment and understanding of mental illnesses.

A nurse is educating a client about mental illness treatment and the client asks, "Why do some medications that treat mental illness take a few weeks to be come effective?" Which of the following statements should the nurse make? a. "It takes a few months to determine the severity of adverse effects before increasing the dose of medications." b. "It takes a few days of treatment to reach therapeutic blood levels." c. "Medications become effective once the client has resolved their stressors." d. "The brain has to establish a new neuronal pathway in response to medications."

d. "The brain has to establish a new neuronal pathway in response to medications." The nurse should identify that the brain has the ability to establish new neuronal pathways or go through a complete neuronal remapping in response to a stimulus. However, it may take weeks or months to reconfigure these pathways.

A nurse is facilitating a new parent health and wellness group. One of the group members states, "I have a history of mental illness in my family. Will my child be affected?" Which of the following responses should the nurse make? a. "Through regular health care provider check-ups, you can prevent mental illness from developing." b. "Your family history does not affect the mental health of your child." c. "Mental illness is a product of your environment, not genetics." d. "There are genetic factors of mental health that may put your child at higher risk of developing manifestations of mental illness."

d. "There are genetic factors of mental health that may put your child at higher risk of developing manifestations of mental illness." Although most mental health disorders cannot be identified through genetics, genetic research like family, adoptive, and twin studies support a genetic correlation between mental health and genetics.

A nurse is educating a client about medication therapy. The client asks, "Is there a method of screening for side effects before starting medications?" Which of the following responses should the nurse make about psychiatric pharmacogenomic testing? a. "is effective for determining your maximum tolerable dose." b. "There is testing available that can determine the effectiveness of medications, but not side effects." c. "Current tests only screen for manifestations and not medication efficacy." d. "Your health care provider can order a test to determine efficacy and severity of adverse effects."

d. "Your health care provider can order a test to determine efficacy and severity of adverse effects." The nurse should identify that psychiatric pharmacogenomic testing is a strategy that a health care provider may choose to utilize that improves the likelihood of selecting an effective psychotropic medication based on the client's genes. This type of testing may also provide the health care provider with information on the severity of adverse effects.

A nurse is caring for a client who recently began taking methylphenidate, a CNS stimulant. Which of the following topics should the nurse prepare to discuss with the client? a. A tolerance to the medication rarely occurs b. An increase in appetite may occur after taking the medication c. The medication should be taken 1 hr before bedtime d. Foods that are known to be high in caffeine should be avoided

d. Foods that are known to be high in caffeine should be avoided The nurse should identify that clients who are prescribed CNS stimulants, such as methylphenidate, should avoid foods that contain caffeine.

A nurse is caring for a client who is experiencing opiate withdrawal. Which of the following findings should the nurse expect to observe? a. Increased heart rate and blood pressure b. Respiratory depression and excessive drowsiness c. Constipation and pupil constriction d. Goose flesh and diarrhea

d. Goose flesh and diarrhea The nurse should identify that in opiate withdrawal, large amounts of norepinephrine are released, causing findings, such as goose flesh, muscle aches, and GI discomfort.

A nurse encourages each client in a group session to speak and be heard. The nurse should identify that this is an example of which of the following ethical principles? a. Beneficence b. Autonomy c. Nonmaleficence d. Justice

d. Justice The nurse should identify that this is an example of justice. Justice involves caring for all clients equally and with the same level of fairness.

A nurse is caring for a client who is experiencing alternating periods of elevated and depressed mood. Which of the following medications should the nurse anticipate the provider to prescribe? a. Benzodiazepine b. Dopamine antagonist c. Selective serotonin reuptake inhibitor d. Mood stabilizer

d. Mood stabilizer The nurse should identify that mood stabilizers, such as lithium, can help prevent a manic or major depressive episode in clients who have bipolar disorder.

A nurse is reviewing the chart of a client who has paranoid schizophrenia. The nurse should identify that the DSM-5 TR distinguishes the different types of schizophrenia based on which of the following criteria? a. Current medication history b. When the manifestations started c. Family history of mental illness d. The client's full history

d. The client's full history The DSM-5 TR criteria can be broken down based on the client's manifestations obtained during the complete health history.

A newly licensed nurse is reviewing the American Nurses Association's core professional values of nursing. Which of the following actions by the nurse demonstrates the value of empowerment? a. The nurse becomes a trainer for the new equipment for other nurses on the unit b. The nurse schedules care around the client's religious practices of daily prayer c. The nurse supports the autonomy of a client who refuses chemotherapy, even though their family wants it d. The nurse provides resources to the client who wants to create a living will before they have surgery

d. The nurse provides resources to the client who wants to create a living will before they have surgery The value of empowerment involves the use of decision making to solve problems for the client. Assisting a client in accessing the resources needed to create a living will is a demonstration of this value.

A nurse is beginning a debrief with staff about a behavioral emergency that resulted in physically restraining a client. The nurse should identify that which of the following is the purpose of debriefing? a. To determine what to say to the client about the incident. b. To determine which members did not perform well. c. To carefully document the entire incident. d. To improve the quality of future responses.

d. To improve the quality of future responses. The purpose of debriefing is to review what happened and determine what should be done to improve the quality of future responses. Debriefing provides staff and clients with the opportunity to discuss how the situation evolved, their feelings, and to promote recovery for the client.