ATI Capstone: Mental Health
A nurse is teaching a client who has a new prescription for paroxetine. Which of the following statements by the client indicates an understanding of the teaching? "I may experience an increased desire to have sex." "My blood pressure may increase." "I may notice excess saliva." "I may not feel like eating as much."
"I may not feel like eating as much."; Anorexia and a decreased appetite are adverse effects of paroxetine.
A nurse is caring for a client who has schizophrenia and was admitted involuntarily. The client states "I don't want to be here. Which of the following statements should the nurse make? "You have the right to legal counsel if you wish." "You have the right to leave the facility against medical advice." "You will need to provide a written explanation about why you wish to leave." "You will need a letter from an attorney stating your decision to discontinue treatment."
"You have the right to legal counsel if you wish."; The nurse should inform the client that they have a right to request legal counsel to review their case regarding their involuntary admission and their desire to be discharged.
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make? "You should be aware that excessive sleeping is an early sign of relapse." "Relapse is an indication that you are not taking your medications properly." "You should keep your provider's and therapist's number with you." "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
"You should keep your provider's and therapist's number with you."; The client should have a written plan, including important numbers, available at all times in case relapse occurs.
A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia. The available medication is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose?
2 tablets
A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A room adjacent to the nursing station A room without a window A room with dim lighting A room containing personal belongings
A room containing personal belongings; A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client? Disclose some personal information to the client to demonstrate approachability. Wait for the client to initiate interaction. Approach the client frequently throughout the day for brief interactions. Adopt a neutral attitude when providing care.
Adopt a neutral attitude when providing care; To promote a therapeutic relationship, the nurse should use a neutral, nonthreatening attitude during care and communication.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? Xenophobia Acrophobia Mysophobia Agoraphobia
Agoraphobia; Agoraphobia is an irrational fear about being in places or circumstances where the client would not have help in the event of panic or other forms of anxiety. Fear of being alone outdoors is a common example.
A nurse is assisting in obtaining informed consent from a client who is scheduled for electroconvulsive therapy. Which of the following actions should the nurse take? Ask the client if they understand the procedure. Inform the client of alternative treatments that are available. Discuss the risks of the procedure with the client. Explain the procedure to the client.
Ask the client if they understand the procedure; The nurse should ask the client if they understand the procedure prior to obtaining their signature on the informed consent form. If the client appears to be incompetent or does not understand the procedure being performed, it is the responsibility of the nurse to notify the provider and document these findings.
A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? Hyperactive bowel sounds Bradycardia Hypertension Dental erosion
Bradycardia; Complications of anorexia include bradycardia and muscle wasting.
A charge nurse is conducting a staff education in service about depressive disorders. Which should the nurse identify as a risk factor for depression? Being married Pregnancy Male gender Chronic illness
Chronic illness; Having a medical illness, especially one that is chronic, is a primary risk factor for depression.
A nurse is assessing a client who is taking lithium. For which of the following findings should the nurse notify the provider? Blood pressure 118/70 mm Hg Weight loss of 2 kg (4.4 lb) in 1 month Client report of sleeping 8 hr per night Coarse tremors of the hands
Coarse tremors of the hands; Coarse tremors of the hands are a manifestation of lithium toxicity. Other manifestations include polyuria, muscle weakness, slurred speech, and sedation. The nurse should notify the provider of this finding so laboratory tests can be prescribed.
A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care? Discourage rest periods during the daytime. Instruct family to avoid visiting during mealtimes. Offer three or four large meals daily. Give the client extra time to communicate needs.
Give the client extra time to communicate needs; Clients who have vegetative signs of depression have slowed thought processes and might take extra time to reply to questions or to verbalize thoughts. The nurse should display patience and give the client extra time to communicate.
A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i am going to do. I cannot even think right now". Which of the following actions should the nurse take? Identify other housing options and sources of transportation. Notify the facility chaplain to request scheduling an appointment. Confirm that everything will be all right because belongings can be replaced. Maintain eye contact with client and summarize the client's feelings.
Maintain eye contact with client and summarize the client's feelings; This demonstrates therapeutic communication. During the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and advocacy.
A nurse is caring for a client who is in recovery from a substance use disorder. The client constantly discusses the destructive actions of people use illicit drugs. Which of the following adaptive defense mechanisms is the client demonstrating? Reaction formation Rationalization Suppression Undoing
Reaction formation; The client is using reaction formation when unacceptable behaviors are controlled and kept out of awareness by developing the opposite behavior. This is an adaptive use of the defense mechanism.
A nurse is discussing types of crises with a newly licensed nurse. Which of the following experiences should the nurse include as an example of maturational crisis? Assault Retirement House fire Job change
Retirement; The nurse should include retirement as an example of a maturational crisis. A maturational crisis is an internal crisis that leads to psychosocial regression or growth. It is a naturally occurring event in a client's life. Other examples of a maturational crisis include marriage, the birth of children, and the death of parents.
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take? Inform the client of consequences. Speak slowly in a low, calm voice. Forbid the client from speaking in an abusive manner. Remain a distance of 1 ft away from the client.
Speak slowly in a low, calm voice; Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and caring.
A nurse is providing discharge teachings 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? The client runs 4 miles outdoors every afternoon. The client drinks 2 liters of liquids daily. The client eats 2 to 3 gm of sodium-containing foods daily. The client eats foods high in tyramine.
The client runs 4 miles outdoors every afternoon; Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.
A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia? Shuffling gait Constant tapping of feet when sitting Sudden onset of high fever Twisting tongue movements
Twisting tongue movements; Twisting tongue movement, tics, sudden involuntary jerking movements of the extremities, and other findings occur in TD. The nurse should notify the provider of these findings since treatment includes reducing dosage of antipsychotic medications or perhaps changing to a second-general antipsychotic medication.
A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery? "I imagine my negative emotions consuming my thoughts." "I imagine solving my problems over and over again." "I imagine myself being overwhelmed during difficult times." "I imagine myself lying on a beach when I start to feel stressed."
"I imagine myself lying on a beach when I start to feel stressed."; Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery.
The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects that the client is suffering from post-traumatic stress disorder if the client makes which of the following statements? "I check any room I enter because the enemy is still after me and could be hiding anywhere." "My child was born with a birth defect due to an exposure I had overseas." "I killed four enemy soldiers with my bare hands and saved my entire battalion." "In my dreams, all I can see are the wounded reaching out and trying to grab me."
"In my dreams, all I can see are the wounded reaching out and trying to grab me."; Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. This client's statement about haunting dreams is typical of a client who has PTSD.
A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching? "You really shouldn't change the schedule we established here in the facility." "Let's work together to devise a time schedule that is convenient for you on a daily basis." "We'll have to talk to your provider about switching to an alternative schedule." "It doesn't really matter what time you take your medications as long as you don't skip any doses."
"Let's work together to devise a time schedule that is convenient for you on a daily basis."; This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the client's needs at this time.
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I think it is going to hurt so I have changed my mind." Which of the following responses should the nurse make? "Your provider wouldn't have requested this if it wasn't necessary." "It is too late to cancel the procedure now." "Don't worry. You will feel so much better afterwards." "Tell me your concerns about the procedure."
"Tell me your concerns about the procedure."; The nurse should encourage the client to express their concerns and fears about the procedure by using open-ended statements. If the client still wants to cancel treatment, the nurse should inform the client that they have the right to refuse treatment at any time. Even if the client changes their mind after the procedure has begun, the client can request to stop the procedure.
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? "The ritualistic behavior provides sexual satisfaction." "The client performs ritualistic behavior to boost self-esteem." "The ritualistic behavior temporarily relieves anxiety." "The client performs ritualistic behavior to decrease feelings of shame."
"The ritualistic behavior temporarily relieves anxiety."; Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to obsessions.
A nurse is providing teaching for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? "You will require a breathing tube during the procedure." "There is a small chance you will have memory loss after this procedure." "There is little risk of having a seizure during this procedure." "You will receive IV or oral contrast prior to this procedure."
"There is a small chance you will have memory loss after this procedure."; Some clients report memory loss for several weeks following the procedure. The nurse should inform the client that this effect usually resolves, but could possibly be permanent.
A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the following information should the nurse include in the teaching? "Use a reliable form of contraception while taking this medication." "If a dose is missed, double the next dose of medication." "This medication may increase your blood pressure." "Do not eat aged cheeses while taking this medication."
"Use a reliable form of contraception while taking this medication."; Alprazolam is a pregnancy category D medication, indicating it causes definitive adverse effects on a fetus.
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy? A client who has been taking amitriptyline for 3 months for depression A client exhibiting psychotic behavior A client admitted 12 hr ago for acute mania A client who is experiencing alcohol intoxication
A client who has been taking amitriptyline for 3 months for depression; Psychotherapy groups provide clients with the opportunity to enhance their personal relationships, increase self-awareness, and try new behaviors in a safe social setting. Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be experiencing improvement in depressive manifestations and be ready to interact in a group setting.
A nurse manager is teaching a group of newly licensed nurses about reportable conditions. Which of the following situations should the nurse manager include as being required by law to be reported? A client who has a substance abuse disorder and is attempting to leave the hospital against medical advice A client who has dementia with multiple wounds and bruises A client who is experiencing post-traumatic stress disorder and reports migraines A client who has terminal cancer and states a desire to die
A client who has dementia with multiple wounds and bruises; A client who has dementia is a vulnerable adult. If abuse is suspected, the nurse has the duty to report the situation.
A nurse is caring for a client who becomes agitated while playing a game of cards with other clients. The client stands up, throws the cards on the floor, and says, "I don't want to play anymore." Which of the following actions should the nurse take? Ignore the client's outburst. Whisper reassuring comments in the client's ear. Allow the client to choose another activity. Ask the client to accompany the nurse to another area.
Ask the client to accompany the nurse to another area; The nurse should ask the client in a calm and nonthreatening manner to walk with them to another area, away from the location of the outburst. Removing the client from the situation will ensure the safety of the other clients as well as deescalate the situation.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which fo the following interventions is the nurse's priority? Recommend that the partner place the client in a long-term care facility. Suggest that the partner see a counselor to help him cope with his exhaustion. Ask the partner to talk about his difficulties in caring for the client. Tell the partner to call a family meeting to get help.
Ask the partner to talk about his difficulties in caring for the client; The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife.
A nurse overhears a visitor ask an assistive personnel (AP), "Can you tell me why my neighbor was admitted?" The AP begins to look up the information. Which of the following actions should the nurse take? Ask to speak with the AP privately. Tell the AP to provide the information. Tell the visitor to speak with the client's provider. Instruct the visitor to fill out an information request form.
Ask to speak with the AP privately; The nurse should stop the AP from disclosing the client's private information and should speak with them privately. The nurse should inform the AP that the client must authorize who and what personal health information is to be shared. Providing this information to the visitor without the client's consent is a breach of the client's confidentiality.
A nurse is initiating a plan of care for a client who has been admitted to a medical unit for acute care of manifestations of anorexia nervosa. Which of the following interventions should the nurse include in the plan? Allow the client to exercise freely. Assess for weekly weight gain of at least 0.9 kg (2 lb) per week. Allow the client to eat meals privately in their room. Sit with the client for 30 min following meals.
Assess for weekly weight gain of at least 0.9 kg (2 lb) per week; The nurse should plan to assess the client's weight for a gain of 0.9 to 1.4 kg (2 to 3 lb) per week. Weight gain of 2.3 kg (5 lb) or more in a week can cause pulmonary edema. If the client does not gain adequate weight, they might need additional calories from supplements or tube feedings.
A nurse is caring for a client on an acute care mental health unit. Client has a history of bipolar disorder and self-injurious behavior. 1330: Client pacing rapidly across their room and shouting loudly at nursing staff. Client appears agitated. Verbal de-escalation measures implemented. Client returned to their bed and is refusing to talk or make eye contact. 1345: Client displays self-injurious behavior by attempting to cut themselves with plastic utensils from their lunch tray. Complete the following sentence by using the lists of options. The nurse should _______________, followed by ____________________.
Assist the charge nurse in placing the client in restraints; Monitoring the client's behavior for their ability to be reintegrated into unit activities is correct. De-escalation techniques failed to help the client and the client is now attempting to harm themselves. In emergency situations, such as client self-harm, the charge nurse is allowed to place the client in restraints with assistance of the nursing staff as needed. The client should be observed and monitored closely throughout their time in restraints. Restraints are a temporary measure to prevent the client from self-harm or harming others.
A nurse in the emergency department is preparing to care for a client who has signs of alcohol intoxication. Which of the following should the nurse plan to include in the client's care? (Select all that apply.) Contact the laboratory to obtain a blood sample. Prepare the client for a CT scan. Check the client's pupil reactivity. Obtain a urine specimen. Perform a developmental screening test.
Contact the laboratory to obtain a blood sample. Prepare the client for a CT scan. Check the client's pupil reactivity. Obtain a urine specimen; Contact the laboratory to obtain a blood sample is correct. A blood sample allows for a blood alcohol level test to be performed.Prepare the client for a CT scan is correct. A CT scan or other neurological tests is performed to rule out brain injury or head trauma.Check the client's pupil reactivity is correct. Checking for pupil reactivity provides information about a client's neurological status.Obtain a urine specimen is correct. A urine specimen is needed to perform a urine toxicology screen.Perform a developmental screening test is incorrect. A developmental screening test is appropriate when needing information about a child or adolescent's maturational or developmental level.
A nurse is teaching a client who has a new prescription for disulfiram about over the counter products that could have potential interactions with this medication. Which of the following products should the nurse include in the teaching? Cough syrup Processed meats Toothpaste Yeast
Cough syrup; The nurse should teach the client to avoid products that contain alcohol such as cough syrup, vanilla extract, cough and cold medications, aftershave lotion, mouthwash, cologne, isopropyl alcohol, and nail polish removers.
A nurse is caring for a client whose partner died 1 year ago. The client states I feel so lonely. I don't go out with my friends anymore. The nurse should identify that the client is isn which of the following stages of grief? Anger Bargaining Depression Denial
Depression; The nurse should identify that the client is in the depression stage of the grieving process. This stage includes withdrawal, regression, and social isolation.
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. The nurse should know that which of the following manifestations is consistent with cocaine intoxication? Nystagmus Dilated pupils Hypersomnia Depression
Dilated pupils; Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system.
A nurse in an outpatient mental health clinic is caring for a client who has an eating disorder.Which of the following findings in the client's medical record indicates the client has bulimia nervosa? 1400: BMI 20.1 Erosion of teeth, numerous dental caries Client reports overeating with subsequent episodes of induced vomiting every weekday evening following work; takes over-the-counter laxative and diuretic medication every morning. Reports good relationship with family and friends. Denies substance use. Reports doing little exercise except on weekends. 1500: 12-lead ECG Sinus rhythm with frequent premature ventricular contractions (PVCs), heart rate 72/min 1600: Potassium 3.2 mEq/L
Erosion of teeth, numerous dental caries Client reports overeating with subsequent episodes of induced vomiting every weekday evening following work Takes over-the-counter laxative and diuretic medication every morning. Sinus rhythm with frequent premature ventricular contractions (PVCs), heart rate 72/min Potassium 3.2 mEq/L BMI 20.1 is correct. Clients who have bulimia nervosa often have a BMI within the expected reference range. Erosion of teeth, numerous dental caries is correct. Erosion of teeth, numerous dental caries, and parotid swelling are manifestations of bulimia nervosa that result from frequent induced vomiting. Overeating with subsequent episodes of induced vomiting every weekday evening following work is correct. Clients who have bulimia nervosa eat excessive amounts of food in a short period of time and then perform compensatory behaviors, such as inducing vomiting. Taking over-the-counter laxative and diuretic medication every morning is correct. Clients who have bulimia nervosa often misuse laxatives and diuretics to rid the body of food and liquid. Frequent premature ventricular contractions (PVCs) is correct. Clients who have bulimia nervosa frequently experience dysrhythmias related to electrolyte imbalances. Sinus rhythm and heart rate 72/min are incorrect. Sinus rhythm is a desired heart rhythm and a heart rate of 72/min is within the expected reference range. Potassium 3.2 mEq/L is correct. Clients who have bulimia nervosa frequently experience electrolyte imbalances, such as hypokalemia, due to loss of potassium with frequent induced vomiting.
A nurse is caring for a client who is in recovery from a substance use disorder and is receiving treatment for withdrawal from heroin. Which of the following manifestations should the nurse expect? Bradycardia Hypertension Slurred speech Pinpoint pupils
Hypertension; Hypertension is a manifestation of opioid withdrawal. Additionally, a client who is experiencing withdrawal can experience tachycardia, hyperthermia, and tachypnea.
A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "you are all making fun of me." Which of the ff behaviors is this client displaying? Grandeur Flight of ideas Erotomania Ideas of reference
Ideas of reference; Ideas of reference occur when a client believes that conversations of others always concern him and that others are ridiculing him.
A nurse is assessing a client who has a prescription for fluoxetine. Which of the following findings is a potential adverse effect of the medication? Urinary retention Bradycardia Increased temperature Orthostatic hypotension
Increased temperature; Hyperpyrexia or fever is a potential adverse effect of fluoxetine. Serotonin syndrome is a rare life-threatening occurrence associated with SSRIs. The effects include fever, tachycardia, elevated blood pressure, sweating, diarrhea, delirium, mood swings, hostility, seizures, apnea, and possible death.
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? Avoid the use of nonverbal gestures to prevent miscommunication. Overlook the client's frustration with communication. Inform the client about scheduled daily activities. Present the client with multiple choices to promote autonomy.
Inform the client about scheduled daily activities; Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day.
The client with bipolar disorder approaches the nurse and reveals fresh, self-inflicted superficial cuts going up and down his right arm. Which of the following actions should the nurse perform first? Implement the client's behavioral modification plan. Document the size and location of the cuts. Inspect the cuts for debris. Administer a tetanus antitoxin.
Inspect the cuts for debris; The first action the nurse should take when using the nursing process is to assess the client, therefore inspecting the cuts is the first action the nurse should take.
A nurse is caring for a client who has schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms of schizophrenia? Auditory hallucinations Delusions Lack of emotion Loose association of ideas
Lack of emotion; The nurse should identify lack of emotion as a negative symptom of schizophrenia. Other negative symptoms can include withdrawal from others, lack of energy, negative self talk, lack of motivation, and feelings of rejection.
A nurse is assessing a client who has antisocial personality disorder. Which of the following characteristics should the nurse expect? Lack of remorse Fear of abandonment Suicidal behaviors Chronic feelings of emptiness
Lack of remorse; Manifestations of antisocial personality disorder include a lack of remorse, a reckless disregard for the safety of one's self and others, and a failure to conform to social norms with respect to lawful behaviors. Clients who have antisocial personality disorder can also be consistently irresponsible, irritable, and aggressive.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving? Leaves the child's room exactly as it was before the loss Volunteers at a local children's hospital Talks about the child in the past tense Visits the child's grave every week after worship services
Leaves the child's room exactly as it was before the loss; Grieving becomes dysfunctional when the client is unable to resume regular activities of daily living or experience emotions other than sadness or depression. An example of dysfunctional grieving is making the loved one's room a shrine for more than a year.
A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 mos. Which of the following interventions should the nurse take? Make a contract with the client not to drive over the speed limit. Call the local police and alert them to the client's car license plate number and the make and model of her car. Ask the client to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. Inform the client that she cannot drink and drive.
Make a contract with the client not to drive over the speed limit; A behavior contract is appropriate to identify the expected behavior and consequences. The client, by signing the contract, assumes responsibility for her behavior.
A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following behaviors should the nurse expect the child to exhibit? Complies with rules Inflated self-esteem Refuses to accept responsibility for actions Is physically cruel to other children
Refuses to accept responsibility for actions; A child who has oppositional defiant disorder can exhibit passive-aggressive behaviors, argue with authority figures, refuse to comply with requests from authority figures, deliberately annoy others, and blame others for their mistakes or misbehavior.
A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first? Encourage the client to discuss the events occurring before the attack. Teach the client relaxation techniques. Tell the client to listen to music. Remain with the client.
Remain with the client; The nurse should remain with the client during a panic attack. This promotes a feeling of safety and reassurance for the client.
A nurse is assessing a toddler during a well child visit. Which of the following findings should the nurse identify and report to the provider as an indication of physical maltreatment? Several round burns on the soles of the feet An abrasion on the elbow Two bruises on the right shin in various stages of healing A contusion on the forehead
Several round burns on the soles of the feet; Although minor injuries are common in toddlers due to their general lack of coordination, the nurse should identify that physical findings such as round burns on the soles of a child's feet can indicate potential physical maltreatment. Burns such as these can be made with a cigarette or a cigar and should alert the nurse to a potential instance of maltreatment that should be reported to the provider.
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect? A dismissal of past failures Psychomotor agitation An increase in energy Sleep disturbances
Sleep disturbances; Sleep disturbances are common in clients with depression.
A nurse is teaching a client who has a new prescription for clozapine about the potential adverse effects of the medication. Which of the following conditions should the nurse include in the teaching? Hair loss Sore throat Loss of appetite Metallic taste in the mouth
Sore throat; Clozapine can cause agranulocytosis. Manifestations of agranulocytosis includes signs of infections such as chills, sore throat, and fever. The client should have complete blood counts to monitor WBC count and absolute neutrophil count (ANC) routinely.
A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first? Coping abilities Support systems Suicide risk Psychiatric history
Suicide risk; The greatest risk to the safety of a client who is depressed is self-harm. Therefore, the priority for the nurse to determine is the client's thoughts or plans for suicide.
