ATI: Mental Health Proctored quiz bank-403 questions

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

"I am able to go to work every day, so I don't have a problem." *Insisting that drinking is not a problem because the client can go to work every day indicates the defense mechanism of denial. This allows the client to ignore the existence of an alcohol use disorder

A nurse is reinforcing teaching with a client who wants to stop smoking by using nicotine lozenges. Which of the following statements should the nurse make? A. "Drink water directly before taking the lozenge." B. "Place the lozenge under your tongue and let it dissolve." C. "Limit your use to no more than 20 lozenges per day." D. "Take 2 4-mg lozenges right after waking up in the morning."

"Limit your use to no more than 20 lozenges per day." *The nurse should instruct the client that users should consume no more than 5 lozenges within 6 hours and should not have more than 20 lozenges per day

A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse make? A. "It is best to discontinue the medication slowly over 1 or 2 months." B. "If the medication hasn't helped you in 3 months, it's not going to." C. "You will likely gain weight if you stop taking the medication." D. "This medication is the only treatment for your condition."

"It is best to discontinue the medication slowly over 1 or 2 months." *The nurse should respond by telling the client that withdrawing from the medication should be done slowly to reduce any manifestations of withdrawal. This can be achieved by reducing the dosage by 25% every 1 to 2 months

A nurse is reinforcing teaching with the guardian of a female adolescent client who has bulimia nervosa. Which of the following statements by the guardian indicates an understanding of the teaching? A. "My daughter is at risk for developing high blood pressure." B. "It is important for my daughter to have regular dental checkups." C. "I should weigh my daughter daily for several weeks." D. "Bleeding during my daughter's periods will increase."

"It is important for my daughter to have regular dental checkups." *For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Therefore, frequent checkups are essential.

A client recently diagnosed with terminal cancer states to the nurse, "I wish I were dead. I have no reason to live." Which of the following responses should the nurse offer? A. "You still have a lot to live for." B. "Please don't talk about that." C. "Your prescribed medication will make you feel better." D. "Have you been thinking of hurting yourself."

"Have you been thinking of hurting yourself." *The nurse's response focuses on the client's underlying feelings and begins to examine the obvious verbal clues of suicidal thoughts. Asking the client about suicidal thoughts is an important intervention by the nurse because if the client is contemplating suicide, the client should be able to discuss these feelings with the nurse

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse provide? A. "You should focus on getting better right now." B. "Why do you think you'll be hospitalized for a long time?" C. "All of your needs will be taken care of while you are in the hospital." D. "Tell me what concerns you most about being hospitalized."

"Tell me what concerns you most about being hospitalized." *Clients with borderline personality disorder have a difficult time identifying their feelings. This response uses open0ended therapeutic communication, which allows the client to focus on concerns about hospitalization and encourages verbalization of feelings

A nurse is caring for a client who has bipolar disorder. After the client is prescribed lithium, his adult child states, "I'm upset that my father is taking this medication." Which of the following responses should the nurse make? A. "It will be alright. You father's provider knows what she is doing." B. "You should be more concerned about your father's mania, which puts him at risk for injury." C. "Tell me what worries you have about your father taking this medication." D. "This is an important medication that will treat your father's condition."

"Tell me what worries you have about your father taking this medication." *This response is therapeutic because it attempts to clarify the family member's concerns and focuses the conversation on the current topic

A nurse is collecting data from a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make? A. "Please try to focus on our conversation." B. "There is nothing over there except a chair." C. "Tell me what you are seeing by that chair." D. "Whatever you are seeing by chair is not real."

"Tell me what you are seeing by that chair." *The nurse should recognize that the client might be experiencing a hallucination and should collect further data about the situation. This response directly asks the client about the hallucination and promotes further communication about the possible perceptual alteration

A nurse is preparing to administer valproic acid 125 mg PO twice daily to a client. Valproic acid 250 mg/5 mL oral suspension is available. How many mL should the nurse administer per dose? (round to nearest tenth)

2.5 mL/dose

A nurse is caring for a client who has alcohol use disorder and claims that her family is "exaggerating the problem." The nurse should identify this behavior as which of the following defense mechanisms? A. Denial B. Introjection C. Regression D. Rationalization

Denial *Denial involves actions and statements by the client that do not acknowledge the reality of the situation

A nurse is collecting data from a client who has brief psychotic disorder. Which of the following manifestations should the nurse expect? A. Evidence of self-mutilation B. Suicidal threats C. Disorganized speech D. Report of chronic depression

Disorganized speech *Clients who have brief psychotic disorder manifest confusion, disorganized speech, delusions, and hallucinations. The behavior can be brought on by a psychosocial stressor

A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following actions should the nurse nurse include in the plan of care? A. Avoid making eye contact with the child B. Rotate staff assignments for the child C. Offer frequent acts of physical affection towards the child D. Give the child a favorite toy to hold

Give the child a favorite toy to hold *The nurse should provide the child with a familiar object such as a favorite toy or a blanket to foster a sense of comfort and security

A nurse is performing a neurological examination for a client. To collect data about a client's level of attention, the nurse should do which of the following? A. Point to 2 objects and ask the client to name them B. Ask the client to name the months of the year in reverse C. Say 3 words and ask the client to repeat them D. Ask the client to write a sentence

Ask the client to name the months of the year in reverse *The nurse should evaluate the client's ability to concentrate by asking the client to name the months of the year in reverse order

A nurse is assisting with the admission of a client who reports hearing voices telling him what to do. Which of the following actions should the nurse take? A. Instruct the client to sit in a quiet place when he hears voices B. Ask the client to repeat what the voices are saying C. Tell the client that the voices do not exist D. Provide therapeutic touch when the client seems anxious

Ask the client to repeat what the voices are saying *The nurse should ask the client directly what the voices are saying to determine if the client or others are in danger or at risk for injury

A nurse is caring for an adult client who has alcohol use disorder. The client states she is refusing further treatment and is leaving the mental health facility. Which of the following actions should the nurse take? A. Request a prescription for restraints from the provider B. Notify security and ask them to lock the unit's exit doors C. Notify the client's family of her intent to leave D. Ask the client to sign an against medical advice form

Ask the client to sign an against medical advice form *The client has the right to refuse treatment and leave the mental health facility unless involuntarily committed. The nurse should ask the client to sign an against medical advice (AMA) form stating that she is choosing to leave the facility against the recommendation of her provider

A nurse is caring for a client who has schizophrenia and is becoming anxious due to auditory hallucinations. Which of the following actions should the nurse take? A. Offer the client therapeutic touch B. Ask the client what he is hearing C. Affirm the presence of the voices D. Move the client into a more stimulating environment

Ask the client what he is hearing *The nurse should ask the client about what he is hearing to determine if the hallucination is causing fear or distress to the client. Also, the nurse needs to determine if the hallucination may cause the client to harm himself or others. However, asking the client, "What are the voices saying to you?" can infer that the nurse believes the voices are real

A nurse is reinforcing teaching with a client who has a new prescription for lorazepam to treat alcohol withdrawal. Which of the following should the nurse identify as an adverse effect of lorazepam that the client should report to the provider? A. Increased thirst B. Sweating C. Blurred vision D. Facial flushing

Blurred vision *The nurse should inform the client that blurred vision is an adverse effect of lorazepam and instruct the client to notify the provider if this occurs

A nurse is collecting data from a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision

Blurry vision *Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria

A nurse in the emergency department is assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse take first? A. Instruct the client to use guided imagery B. Move the client to a quiet area C. Assist the client in identifying his coping skills D. Allow the client time to express his feelings

Move the client to a quiet area *The greatest risk to this client is increased anxiety; therefore, the nurse should first move the client to a quiet area to decrease excessive stimuli

A nurse is contributing to the plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client? A. Explaining that tube feeding are necessary if the client refuses oral intake B. Weighing the client each day prior to any oral intake C. Permitting the client to spend some quiet time alone after each meal D. Refraining from commenting on what the client is eating during mealtime

Permitting the client to spend some quiet time alone after each meal *The nurse should directly observe the client for at least an hour following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for this client's plan of care

A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. Which of the following actions should the nurse take? A. Discourage the client from taking naps during the day B. Allow the client to choose which items of clothing to wear each day C. Encourage the client to participate in group therapy D. Provide high-calorie finger-foods frequently

Provide high-calorie finger-foods frequently *The nurse should offer the client frequent high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client's intake when mania makes sitting down and concentrating on a meal

A nurse is assisting with the planning of a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nurse include during the orientation phase of group development? A. determine the rules that the group will follow B. address disagreements among group members C. help clients work through the grief response D. transition from the role of leader to facilitator

determine the rules that the group will follow *during the orientation phase of group development, the nurse should determine the rules that apply to the group and ensure that all members understand these rules. Examples of rules to be discussed include confidentiality and meeting times.

A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. The client tells the nurse, "I have not had anything to drink for 6 hours." Which of the following findings should the nurse expect during alcohol withdrawal? A. Low body temperature B. Insomnia C. Muscle flaccidity D. Bradycardia

Insomnia *The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia and restlessness

A nurse in a mental health facility is assisting with the care of a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit? A. Lack of remorse B. Self-mutilation C. Delusional behavior D. Splitting

Lack of remorse *A client who has antisocial personality disorder lacks empathy for others and shows no remorse of guilt for callous behavior

A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem-solving skills B. Understanding the medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration

Maintaining adequate hydration *The priority goal for this client is to prevent physical exhaustion, maintain health, and meet nutritional and rest needs during the acute phase of the client's manic episode.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take? A. Administer oxygen B. Administer an anticonvulsant C. Administer an opioid antagonist D. Administer IV fluids

Administer oxygen *In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status is stable

A public health nurse is planning methods of providing health assistance for community members. Which of the following community interventions is an example of primary prevention? A. Serving as a staff member in a rape crisis center B. Provide referrals to 12 step programs for community members being discharged from rehabilitation centers C. Demonstrating stress-release exercises to members of the community D. Leading a support group for newly divorced community members

Demonstrating stress-release exercises to members of the community *This intervention is an example of primary prevention. By instructing community members about ways to manage stress, the nurse can assist in minimizing the harmful effects of stress that can lead to future illness

A nurse is collecting data from a client who has conduct disorder. Which of the following findings should the nurse expect? A. Fearfulness of authority figures B. Flat affect C. Preoccupation with enforcing rules D. Aggressive behavior toward others

Aggressive behavior toward others *The nurse should expect a client who has conduct disorder to exhibit aggression towards others and impulsively violate others' rights

A nurse in an acute substance disorder unit is collecting data from a client who received treatment in the emergency department for an opioid overdose. Which of the following findings should the nurse anticipate during opioid withdrawal? A. Calmness B. Anxiety C. Hypotension D. Bradycardia

Anxiety *The nurse should expect the client to have anxiety during opioid withdrawal

A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take? A. Focus on the client's delusions B. Debate the content of the delusions with the client C. Validate that the delusions are real D. Ask the client to describe his feelings about the delusions

Ask the client to describe his feelings about the delusions *The nurse should ask the client to describe his feelings and beliefs about delusions. Identifying these feelings and beliefs can help determine the underlying issues and feelings that the client needs to address

A school nurse is providing care to a student who is angry and states, "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing? A. Chronic grief B. Uncomplicated grief C. Disenfranchised grief D. Delayed grief

Disenfranchised grief *Disenfranchised grief occurs when social expectations restrict an individual's ability to cope with grief in an expected way. This type of grief can occur when the social relationship between the client and another individual who has an uncomplicated form of grief

A nurse in an ambulatory clinic is caring for a client who has an injured arm and periorbital ecchymosis. The nurse suspects intimate partner violence. Which of the following nursing interventions should the nurse take first? A. Notify the nursing supervisor B. Prepare the client for an X-ray C. Contact social services D. Check the client's injuries

Check the client's injuries *The first action the nurse should take using the nursing process is to assess the client

A nurse is caring for a client who has conduct disorder and is displaying violent behavior. After several attempts to provide a diversion, the nurse applies a physical restraint. Which of the following actions should the nurse take? A. Check the client's physical needs every 30 minutes B. Obtain the client's vital signs once per shift C. Tie the restraint to the side rail of the client's bed D. Use square knots to secure the client's restraint

Check the client's physical needs every 30 minutes *While the client is in restraints, the nurse should check the client's physical needs every 30 minutes. The nurse should offer food and hydration and should allow the client to use the bathroom if necessary. The nurse should also document these findings

A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medication should the nurse expect the provider to prescribe to assist the client in maintaining sobriety? A. Varenicline B. Clonidine C. Buprenorphone D. Disulfiram

Disulfiram *Disulfiram is a type of aversion therapy that helps clients abstain from alcohol. Drinking alcohol while taking this medication produces a toxic reaction that causes swelling, confusion, headaches, breathing difficulties, and other manifestations

A nurse is reinforcing teaching for a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which of the following manifestations is an adverse effect of this medication? A. Oliguria B. Tinnitus C. Dizziness D. Insomnia

Dizziness *The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined

A nurse in an urgent care clinic is collecting data from a client who reports recent cocaine use. Which of the following manifestations should the nurse expect? A. Hypertension B. Drowsiness C. Bradycardia D. Pinpoint pupils

Hypertension Cocaine is a central nervous system stimulant. Therefore, hypertension is an expected finding in a client who has recently used cocaine

A nurse is collecting data from a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? A. Decreased appetite B. Slurred speech C. Insomnia D. Hallucinations

Hallucinations *Hallucinations are a manifestation of severe alcohol withdrawal. Other manifestations of severe alcohol withdrawal include diaphoresis, hyperthermia, and tachycardia

A nurse is heling evaluate the plan of care for a client who has antisocial personality disorder. Which of the following client actions indicates that he is making progress with the treatment? (select all that apply) A. Assisting another client who has depression to fill out a menu B. Nominating himself to chair the client government meeting C. Requesting a weekend pass to go home D. Serving as the judge for a unit talent show E. Informing the nurse that the staff provides excellent care to clients

1. Assisting another client who has depression to fill out a menu 2. Requesting a weekend pass to go home *Clients who have antisocial personality disorder tend to lack empathy for others and often display an inability to connect with others. Assisting another client indicates the client's willingness to help and connect with others and demonstrates rules and have a lack of respect for authority. Requesting a weekend pass indicates the client's willingness to follow unit rules and demonstrates progress with treatment

A nurse in an acute mental health facility is assisting with the plan of care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse recommend? A. Encourage the client to focus on personal hygiene B. Limit the hours the client sleeps each day C. Instruct the client to practice thought-stopping D. Make negative statements about the client's behavior

Instruct the client to practice thought-stopping *The nurse should suggest thought-stopping as an intervention for this client who has OCD. By saying "stop" out loud, the client can learn to interrupt obsessive thought.

A nurse is assisting with the admission of a client who has opioid use disorder. Which of the following manifestations should indicate to the nurse that the client is experiencing opioid withdrawal? A. Hypertension B. Sedation C. Hypothermia D. Bradycardia

Hypertension *The nurse should identify that hypertension is a manifestation of opioid withdrawal. Other manifestations of opioid withdrawal can include tachycardia, enlarged pupils, increased body temperature, tachypnea, diaphoresis, rhinorrhea, anxiety, muscle spasms, nausea and vomiting, and abdominal cramping

A nurse is preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take? A. Make sure the caregiver is present when interviewing the client B. Document how the caregiver responds when told that the client looks neglected C. Ask the client why she refuses to eat the caregiver's food D. Identify sources of stress for the caregiver

Identify sources of stress for the caregiver

A nurse is caring for a client with schizophrenia who started taking a first-generation antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify that the client is experiencing which of the following adverse effects of antipsychotic medications? A. Neuroleptic malignant syndrome B. Akathisia C. Anticholinergic toxicity D. Opisthotonos

Akathisia *Akathisia is an extrapyramidal adverse effect that occur in a client within the first 2 months after beginning a first-generation antipsychotic medication. The client might be unable to rest due to a feeling of inner restlessness. Rocking back and forth and pacing the floor can also be manifestations of akathisia. The nurse should report this finding to the provider. Several medications such as propranolol can be used to treat akathisia

A nurse in an acute mental health facility is reviewing the medication records of a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? A. Depression B. Schizophrenia C. Obesity D. Alzheimer's disease

Alzheimer's disease *The nurse should expect a prescription for memantine for a client who has moderate to severe Alzheimer's disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and to improve cognitive function

A nurse delegates a newly licensed nurse to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching? A. Accompanies the client to physical and occupational therapy B. Ambulates the client's roommate while the client sleeps C. Asks the nurse at lunch time to assign another newly licensed nurse to perform this task D. Remains with the client while family members are visiting

Ambulates the client's roommate while the client sleeps *One-on-one observation requires constant supervision of the client. The client might wake up and engage in self-injuries behavior while the newly licensed nurse is caring for the other client

A nurse is assisting with the collection of admission data for a client who has anorexia nervosa. The client has lost 11.4 kg (25 lb) over the past month and currently weights 38.6 kg (85 lb). The nurse should expect which of the following findings? A. Flushed extremities B. Hyperkalemia C. Loose stools D. Amenorrhea

Amenorrhea *The nurse should expect this client who has anorexia nervosa to have amenorrhea due to low body weight

A nurse in an acute mental health facility is participating in a nursing staff discussion about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include? A. A client who is involuntarily admitted must take prescribed medications B. An involuntary admission of a client is limited to 2 weeks C. A client who is involuntarily admitted can leave the facility against medical advice D. An involuntary admission is justified if the client is a danger to others

An involuntary admission is justified if the client is a danger to others *A client who is a danger to others or to self qualifies for an involuntary admission. The inability to meet basic needs due to the need for mental health treatment is also a justification for an involuntary admission

A nurse is assisting with the admission of a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display? A. Relief about finally receiving care for a problem for which was previously afraid to ask for B. Anger with the nursing staff for hospitalizing him against his will C. Withdrawal from others due to shame over his recent actions D. Remorse for stealing and destroying the car

Anger with the nursing staff for hospitalizing him against his will *A client who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation goes against his will or desires

A nurse in a provider's office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client's mood? A. Anergia B. Flat effect C. Apathy D. Anhedonia

Anhedonia *Anhedonia is an inability to experience pleasure. This finding is especially concerning when the client no longer enjoys the activities that once produced pleasure

A nurse on an eating disorders acute care unit is collecting data from a client and observes the presence of lanugo on her skin. The nurse should identify that this finding is consistent with which of the following eating disorders? A. Anorexia nervosa B. Bulimia nervosa C. Binge eating disorder D. Pica

Anorexia nervosa *Anorexia nervosa is an eating disorder associated with severe food restriction. Clients who have anorexia nervosa are often underweight and might have lanugo (fine, downy hair) on the back and face

A nurse is caring for a client who has cirrhosis of the liver due to alcohol use disorder. Which oft he following findings should the nurse expect? A. Acrocyanosis B. Arrhythmias C. Ascites D. Weight gain

Ascites *The nurse should expect this client who has cirrhosis of the liver to exhibit gastrointestinal and hepatic manifestations due to the destruction of liver cells. Ascites results from the accumulation of serous fluid in the abdominal cavity due to portal hypertension. Jaundice, weight loss, and esophageal varices are other expected findings of this disorder

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurse's priority? A. Ask the client what the voices are saying B. Focus the client's attention on reality-based activities C. Make eye contact when speaking with the client D. Encourage the client to listen to music through headphones

Ask the client what the voices are saying *The greatest risk for this client is an injury to self or others due to command hallucinations. Command hallucinations can be a psychiatric emergency. Therefore, the nurse's priority is to ask the client what the voices are saying

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A. Assertive community treatment B. Supportive group C. Private counseling D. Vocational rehabilitation services

Assertive community treatment *Evidence-based practice indicates the nurse should first refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so inpatient hospitalization can be avoided

A nurse is assisting a client whose house was just destroyed by a fire. Which of the following actions should the nurse take? A. Assist the client in identifying resources B. Give the client a time frame in which to find shelter C. Assure the client that everything will work out D. Encourage the client to focus on actions and not emotions

Assist the client in identifying resources *The client who is experiencing a crisis will often feel overwhelmed by the event. The nurse should assist by offering emotional support and identifying resources to help the client

A nurse is collecting data from a client who has schizophrenia and was recently admitted to acute care. Which of the following findings should the nurse expect? A. Seductive behaviors B. Obsession with rituals C. Uncontrolled appetite D. Associative looseness

Associative looseness *The nurse should recognize associate looseness (speech that reveals though patterns that shift rapidly between topics) as a common finding in a client who has schizophrenia. Other findings include the presence of delusions, hallucinations, and altered speech patterns such as echolalia

A nurse is observing a client who has schizophrenia. The client is in the dayroom when another client asks him if 2 items of clothing match. He replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations? A. Clang association B. Echolalia C. Word salad D. Associative looseness

Associative looseness *This client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts in succession

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die." The client is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse's priority? A. Obtain a prescription for PRN medication for agitation B. Attempt to reduce environmental stimuli C. Request a prescription for physical restraints D. Place the client in seclusion

Attempt to reduce environmental stimuli *Least restrictive to the client that does not jeopardize the client's safety

A nurse in a provider's office is reviewing the laboratory reports of a client who has bulimia nervosa. Which of the following laboratory values indicates a therapeutic response to the treatment plan? A. BUN 15 mg/dL B. Potassium 3.2 mEq/L C. Sodium 130 mEq/L D. Hematocrit 54%

BUN 15 mg/dL *Clients who have bulimia nervosa often have increased BUN levels due to dehydration. This level is within the expected reference range of 10 to 20 mg/dL, indicating a therapeutic response to the treatment plan

A nurse is caring for a client who is terminally ill. The client states, "if only I had gone to my doctor earlier." The nurse should identify that the client is in which of the following Kubler-Ross stages of grief? A. Bargaining B. Anger C. Depression D. Denial

Bargaining *The client is in the bargaining stage of grief. During this stage, the client can have feelings of helplessness and vulnerability

A nurse is reinforcing teaching with a client who has generalized anxiety disorder to perform a deep-breathing exercise. Which of the following actions should the nurse instruct the client to take? A. Utilize chest breathing B. Breathe in through the nose C. Keep the shoulder erect D. Repeat the exercise for at least 10 minutes for effectiveness

Breathe in through the nose *When using deep-breathing exercises, clients should breathe in through their noses, hold their breath for about 3 seconds, and then exhale through their mouths

A nurse is reviewing the medical history of a client who has a new prescription for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as the priority? A. Severe depression B. Cardiac arrhythmia C. Bipolar disorder D. Parkinson's disease

Cardiac arrhythmia *A client who has cardiac arrhythmias need further evaluation. The nurse should identify that the greatest risk for death due to ECT is related to cardiac complications

A nurse is collecting data from a client who has schizophrenia. The client suddenly states, "I'm blue, so are you, and I'm leaving on a choo, choo, choo!" The nurse should identify the client's statement as which of the following speech patterns? A. Clang association B. Word salad C. Neologism D. Echolalia

Clang association *This statement demonstrates clang association, a pattern of speech often used by clients who have schizophrenia. This pattern of speech often includes rhyme or a string of words that have the same beginning sounds

A nurse is assisting with the care of a client who has schizophrenia and is being discharge from an acute mental health setting. Which of the following should be included in the discharge plan? A. Refer the client to respite care services B. Provide a list of primary preventative mental health group C. Enroll the client in a 12-step program D. Contact an intensive outpatient program

Contact an intensive outpatient program *A client who has received in-patient treatment for schizophrenia can benefit from an intensive outpatient program. These programs allow clients to receive step-down care similar to what was provided in the inpatient setting to stabilize their condition further

A nurse is caring for a client who has newly diagnosed with breast cancer that has metastasized in to the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kubler-Ross' grief theory? A. Anger B. Bargaining C. Denial D. Depression

Denial *During the first stage, denial and refusal to accept the imminence of the loss are self-protection mechanisms that allow the client to process the diagnosis. During this stage, the client has difficulty accepting the loss or diagnosis and might refuse to discuss the impending or actual loss during this stage. The client might also be convinced that a mistake has been made and that there is no loss

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client? A. Bargaining B. Depression C. Denial D. Anger

Denial *The nurse should expect the client to deny the reality of the diagnosis initially. This is a protective reaction seeking to avoid psychological pain

A nurse is reviewing the medical record of a client who has bulimia nervosa. Which of the following findings should the nurse expect? A. Elevated creatinine level B. Decreased white blood cells C. Dental erosion D. Cachexia

Dental erosion *The nurse should expect dental erosion in a client who has bulimia nervosa. The binging and purging behavior with induced vomiting leads to dental caries and enamel erosion from the hydrochloric acid content of emesis. Induced vomiting can also cause parotid swelling. Continued vomiting can place the client at risk of esophageal or gastric rupture

A nurse is caring for a client who has a stimulant use disorder. Which of the following manifestations should indicate to the nurse that the child is experiencing withdrawal? A. Mental alertness B. Tachycardia C. Depression D. Dilated pupils

Depression *A client who has a stimulant use disorder and is experiencing withdrawal can experience depression. Other manifestations of stimulant withdrawal can include fatigue, paranoia, craving for stimulants, anxiety, increased appetite, poor concentration, hypersomnia or insomnia, and irritability

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions is the nurse's priority? A. Offer the client finger foods every 2 hr B. Determine if the client is a danger to herself C. Monitor the client's vital signs every 2 hr D. Move the client to a quiet area

Determine if the client is a danger to herself *The greatest risk to this client is an injury from hyperactivity or life-threatening exhaustion. Therefore, the priority action is to determine whether the client has feelings of suicide or is showing manifestations of exhaustion

A nurse in a community urgent care facility is helping plan interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis

Determine if the client is experiencing thoughts of self-harm *The nurse should determine whether the client has thoughts of self-harm following a sexual assault or other crisis situations. The nurse's priority is to ensure the client's safety.

A nurse is assisting with the admission of a client who has alcohol use disorder and is experiencing withdrawal. Which of the following actions is the nurse's priority? A. Pad the side rails of the client's bed B. Assign the client to a private room C. Collect a urine sample from the client D. Determine the client's level of disorientation

Determine the client's level of disorientation *The greatest risk to this client is self-injury from the alcohol withdrawal; therefore, the priority action the nurse should take is to determine the client's level of disorientation to ensure the client is safe from self-injury or harm

A nurse is caring for a client with borderline personality disorder who has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups? A. Co-dependents support group B. National Alliance on Mental Illness C. Dialectical behavior treatment group D. Dual diagnosis treatment group

Dialectical behavior treatment group *The nurse should encourage the client to participate behavior treatment group that focuses on interventions for suicidal and destructive behaviors

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care? A. Buprenorphine B. Diazepam C. Varenicline D. Rimonabant

Diazepam *The nurse should expect to administer diazepam to a client during alcohol detoxification. Anti-anxiety agents such as chlordiazepoxide and diazepam are long-acting CNS depressants that are used to minimize the manifestations of alcohol withdrawal

A nurse is contributing to the plan of care for a client who has alcohol use disorder. Which of the following medications should the nurse plan to administer? A. Methadone B. Varenicline C. Buprenorphine D. Diazepam

Diazepam *The nurse should plan to administer diazepam to this client who has alcohol use disorder to minimize manifestations of alcohol withdrawal.

A nurse is assisting with the admission of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? A. Reluctance to confide in others B. Doubting the trustworthiness of others C. Holding grudges against others D. Disregarding the safety of others

Disregarding the safety of others *A client who has antisocial personality disorder can disregard the safety of others. Other manifestation of this disorder can include deceitfulness, impulsiveness, and a lack of remorse

A nurse in a rehabilitation unit is discharging a client who has alcohol use disorder. Which of the following prescriptions should the nurse anticipate for the client? A. Phenobarbital B. Disulfiram C. Varenicline D. Methadone

Disulfiram *The nurse should anticipate a prescription for disulfiram for a client who is in the maintenance phase of alcohol withdrawal. Disulfiram promotes refraining from alcohol through aversion therapy. Any intake of alcohol while the client is taking the medication will result in intense nausea and vomiting, headaches, respiratory difficulties, and confusion

A nurse is caring for a client who has alcohol use disorder. Following alcohol withdrawal, which of the following medications should the nurse expect to administer to the client during maintenance? A. Methadone B. Disulfiram C. Chlordiazepoxide D. Naloxone

Disulfiram *The nurse should expect to administer disulfiram as a deterrent to prevent future use of alcohol. The nurse must ensure the client has not had any alcohol intake for at least 12 hours prior to administration

A nurse is reinforcing teaching with a client who has a prescription for lithium. Which of the following instructions should the nurse include in the teaching? A. Take this medication on an empty stomach B. Drink 2 L of fluid each day C. Use a salt substitute to season foods D. Take ibuprofen for headaches

Drink 2 L of fluid each day *The nurse should instruct the client to drink at least 2 to 3 L of fluid per day to remain hydrated and to consume a consistent amount of sodium. Low sodium levels can result in lithium toxicity

A nurse is assisting with planning care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects? A. Hypertension B. Drowsiness C. Panic attacks D. Diarrhea

Drowsiness *Drowsiness is an expected side effect of amitriptyline and other tricyclic antidepressants. Sedation will likely be present during the first few weeks of treatment with amitriptyline and put the client at risk for falls

A nurse is administering alprazolam for the first time to a client who has anxiety. The nurse should monitor the client for which of the following adverse effects of this medication? A. Tinnitus B. Elevated blood pressure C. Drowsiness D. Bleeding gums

Drowsiness *The nurse should be aware that alprazolam, a benzodiazepine, commonly causes CNS depression, including drowsiness. When administering this medication to a client for the first time, the nurse should monitor the client for drowsiness and implement interventions to reduce the risk of falls or injury

A nurse is collecting data from a client who takes an MAOI for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? A. Elevated blood pressure B. Weight gain C. Muscle twitching D. 2+ peripheral edema

Elevated blood pressure *The greatest risk to the client is an elevated blood pressure, which increased the risk of a hypertensive crisis that can result from taking an MAOI.

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. Blurred vision B. Urinary retention C. Muscle flaccidity D. Elevated temperature

Elevated temperature *Elevated temperature is a manifestation of neuroleptic malignant syndrome that should be immediately reported to the provider. Other symptoms of the syndrome include rigidity, sweating, dysrhythmias, and fluctuations in blood pressure

A nurse is contributing to the plan of care for a client with bipolar disorder who has acute mania. Which of the following interventions should the nurse recommend including in the plan? A. Provide the client with a low-calorie, low-fat diet B. Encourage the client to have frequent rest periods C. Escort the client to daily group therapy D. Limit the client's intake of caffeinated beverages to 12 oz per day

Encourage the client to have frequent rest periods *The nurse should recommend encouraging frequent rest periods throughout the day to decrease the client's risk of exhaustion from the constant activity associated with acute mania.

A nurse is planning care for a newly admitted client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse recommend for this client? A. Rotate staff assignments for the client B. Refrain from discussing the client's maladaptive coping strategies C. Wait for the client to initiate interactions with staff members D. Encourage the client to participate in group therapy

Encourage the client to participate in group therapy *Clients who have PTSD can benefit from group therapy. Sharing with others who have the same experiences has been effective therapy

A nurse on an acute mental health unit is caring for a client who is experiencing a manic episode with agitation. Which of the following actions should the nurse take? A. Schedule the client for group therapy B. Discourage the client from napping during the day C. Encourage the client to participate in physical activity D. Allow the client to spend time alone

Encourage the client to participate in physical activity *Offering the client who is experiencing a manic episode an opportunity for physical activity can decrease stress and provide an outlet for the client's excessive energy and agitation

A nurse on a mental health unit is caring for a client who has social anxiety disorder and is exhibiting signs of panic. Which of the following actions should the nurse take to reduce the client's level of anxiety? A. Accompany the client to an area with increased environmental stimuli B. Suggest that the client lies down and rests C. Place the client in seclusion D. Encourage the client to practice deep breathing

Encourage the client to practice deep breathing *The nurse should encourage the client to practice slow deep-breathing exercises to elicit relaxation. The nurse should demonstrate the technique and practice it along with the client. Focus on taking slow, deep breaths can help divert the client's attention from feelings of anxiety

A nurse is caring for a client who has schizophrenia and is experiencing auditory and visual hallucinations. Which of the following actions should the nurse take? A. Ask the client what the voices are saying B. Encourage the client to use reality testing C. Limit the client's exposure to noise D. Place the client in seclusion

Encourage the client to use reality testing *A client who is experiencing hallucinations can become frightened or agitated. The nurse should encourage the client to perform reality testing during periods of hallucinations by looking at the faces of other clients in the area. If the other clients do not appear frightened, the client should identify that the perception is a hallucination and not real.

A nurse is caring for a child who has a diagnosis of terminal brain cancer. The mother states, "I feel numb and can't believe this is happening to us." Which of the following interventions is the nurse's priority? A. Explore effective ways of family coping B. Encourage the family's expression of their feelings C. Discuss the disease and its manifestations with family members D. Instruct the family about anticipatory grieving

Encourage the family's expression of their feelings *The first action the nurse should take using the nursing process is to assess the family by encouraging them to express their feelings about their child's illness. This assessment will allow the nurse to understand the particular needs of the family better as they prepare to face their child's death

A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take? A. Encourage the client to attend assertive behavior sessions B. Ensure staff members set limits on the client's behavior C. Tell the client to socialize more with other clients on the unit D. Frequently implement measures to increase the client's self-esteem

Ensure staff members set limits on the client's behavior *The nurse should ensure all staff members set limits on the client's behavior. The limits should be clear and realistic and realistic and address specific behaviors. Also, the nurse should provide clear boundaries and consequences for the client

A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include to address limit-setting? A. Instruct the client to use reaction formation for behavior control B. Recommend the client attend assertiveness training C. Establish and explain consequences of the client's behavior D. Encourage the client to increase socialization

Establish and explain consequences of the client's behavior *The nurse should communicate desired behavior and expectations to the client, as well as the detailed consequences of not meeting them. When addressing limit-setting with the client, these expectations and consequences should be included in the plan of care

A nurse in a provider's office is reinforcing teaching with a client who is experiencing stress due to the loss of a job. Which of the following instructions should the nurse give? A. Drink no more than 6 cups of coffee per day B. Exercise for 140 minutes each week C. Get 6 hours of sleep every night D. Sleep 30 minutes later each morning

Exercise for 140 minutes each week *The nurse should instruct the client to exercise for 140 minutes per week, or 20 min per day, by participating in moderate-intensity aerobic activities such as walking. Exercise can reduce stress and increase endorphin levels

A nurse is reestablishing a therapeutic relationship with a client. Which of the following actions should the nurse perform during the orientation phase of the the relationship? A. Research the client's condition B. Explain confidentiality to the client C. Provide the client with information about her disorder D. Summarize the client's goals

Explain confidentiality to the client *The nurse should explain confidentiality to the client during the orientation phase of the therapeutic relationship. Other tasks the nurse should accomplish during this phase include establishing a rapport and specifying a contract containing the date, time, and place of future meetings with the client

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider immediately? A. Constipation B. Fever C. Weight gain D. Dry eyes

Fever *When using the urgent vs non-urgent approach to client care, the nurse should recognize that the priority adverse effect that should be reported to the provider when taking haloperidol is flu-like manifestations such as fever, a sore throat, fatigue, and muscle stiffness. These manifestations may indicate neuroleptic malignant syndrome, which is a life-threatening reaction to some antipsychotic medications

A nurse on a mental health unit is preparing to discharge a client who has bulimia nervosa. Which of the medications should the nurse expect the provider to prescribe for the client? A. Paroxetine B. Fluconazole C. Bupropion D. Fluoxetine

Fluoxetine *The nurse should expect the provider to prescribe fluoxetine for a client who has bulimia nervosa. It is an SSRI used most frequently for the treatment of depression. It is thought to assist in the treatment of binge eating associated with bulimia by decreasing the craving for carbohydrates. It is prescribed for bulimia at 3 times the dosage that is used for the treatment of depression

A nurse is assisting with preparing an in-service session about Alzheimer's disease for a group of newly licensed nurses. Which of the following findings should the nurse include as an early manifestation in the progression of the disease? A. Forgetting material that was just read B. Losing the ability to feel emotions C. Experiencing changes in physical abilities such as swallowing D. Having difficulty controlling the bladder

Forgetting material that was just read *Forgetting material that has just been read is a sign of mild Alzheimer's and is an early manifestation of the disease. Mild memory impairment includes recent memory. Gradually, deterioration progresses to include both recent and remote memory

A nurse in an assisted living facility is collecting data on an older adult client. Which of the following findings should the nurse identify as expected age-related changes? A. Forgetting the days of the week B. Challenges with problem-solving C. Decreased judgment D. Withdrawal from social activities

Forgetting the days of the week *The nurse should identify that forgetting the day of the week and remembering it later is an expected age-related change in older adult clients. Other findings can include needing assistance when operating devices such as a microwave, making occasional errors when balancing a checkbook, having difficulty finding the correct use of a word, and becoming tired after family gatherings or social activities

A nurse in an acute care mental health facility observes a client who has bipolar disorder to begin to shout and use offensive language toward a visitor. Which of the following actions should the nurse take? A. Give the client 2 options for ending the situation B. Move quickly to stand directly in front of the client before speaking C. Direct other clients to move toward the client as a show of force D. Tell the client that the conversation will be ended if the shouting continues

Give the client 2 options for ending the situation *Giving the client several options (e.g. 2 different location in which to be away from visitors and other clients) prevents the client from feeling powerless and gives the client some responsibility for making choices

A nurse is collecting data from a client who reports being abused by his partner. Which of the following actions should the nurse take? A. Tell the client that he is morally obligated to press charges against his partner B. Inform the client that photographs of his injuries must be taken C. Tell the client that he will be taken to a safe house D. Give the client a detailed explanation of all of the procedures that must be performed

Give the client a detailed explanation of all of the procedures that must be performed *A client who reports abuse will often experience fear and anxiety. Providing sensitive and supportive care by explaining all procedures and providing privacy for the client can decrease the client's anxiety and feelings of vulnerability

A nurse on an inpatient mental health unit is caring for a client who is angry and showing signs of potential violence. Which of the following actions should the nurse take to de-escalate the client's anger? A. Call security personnel for a show of force B. Inform the client that restraints will be used as a consequence for verbal abuse C. Speak to the client in a loud, forceful voice D. Give the client extra personal space

Give the client extra personal space *A client who is experiencing escalating anger requires additional space to feel less threatened. The nurse should stand 1 foot farther away from the client than the client's arms and legs can reach

A nurse is collecting data from a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? A. Calling family members B. Spending time alone C. Giving away possessions D. Excessive crying

Giving away possessions *Giving away possessions indicates that this adolescent client is a the greatest risk for suicide. The nurse should have a relationship built on trust an respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. Therefore, this is the priority finding for the nurse to report to the treatment team

A nurse is collecting data from a client who was brought to the emergency department by a friend. The friend reports that the client inhaled a large amount of cocaine. Which of the following findings should the nurse expect? A. Depressed mood B. Hallucinations C. Severe hypotension D. Bradycardia

Hallucinations *Cocaine is central nervous stimulant; therefore, the nurse should expect this client with cocaine intoxication to have hallucinations and delirium. Other manifestations of cocaine intoxication include grandiosity, euphoria, elevated blood pressure, tachycardia, and dilated pupils

A nurse is assisting with the admission of a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia? A. Anhedonia B. Avolition C. Flat affect D. Hallucinations

Hallucinations *Positive manifestations of schizophrenia include behaviors or thought patterns that are not usually present. Hallucinations are a positive manifestation of schizophrenia. Other positive manifestations are religiosity, delusions, paranoia, and disorganized speech

A nurse is collecting fata from a client who was diagnosed with schizophrenia. The nurse should identify that which of the following findings is considered a positive symptom of schizophrenia? A. Hallucinations B. Social withdrawal C. Anergia D. Flat effect

Hallucinations *Positive symptoms fall into the following categories: content of thought, form of thought, perception, or sense of self. The nurse should identify that hallucinations fall under the category of perception and cause the client to experience sensory perceptions that are not associated with reality. Other positive symptoms include delusions, depersonalization, and concrete thinking

A nurse is caring for a client who has been taking fluoxetine for anxiety. Which of the following adverse effects of this medication should the nurse report to the provider immediately? A. Mydriasis B. Hallucinations C. Arthralgia D. Sexual dysfunction

Hallucinations *The nurse should identify that hallucinations can be an adverse effect of fluoxetine and can also indicate that the client is experiencing serotonin syndrome. Serotonin syndrome can be caused by too high a dose of fluoxetine or an interaction with another medication. Other adverse effects of serotonin syndrome can include diarrhea, sweating, fevers, tachycardia, abdominal pain, and increased blood pressure. The nurse should notify the provider immediately

A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min C. Conjunctival discharge D. Respiratory rate 28/min

Heart rate 118/min *The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia

A nurse is caring for a client who presents with a fractured wrist. The nurse suspects intimate partner violence. Which of the following interventions is the nurse's priority? A. Help the client develop a safety plan B. Teach the client empowerment skills C. Provide information about a support group for intimate partner abuse D. Make a follow-up appointment with the primary provider

Help the client develop a safety plan *The greatest risk to this client is further injury from the partner; therefore, the priority intervention for the nurse is to help the client develop a safety plan for a rapid escape if further violence occurs

A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder? A. Prevents the need for mood-stabilizing medications B. Helps the client deal with distorted thought processes C. Aids in communication among family members D. Replaces the need for lifestyle interventions

Helps the client deal with distorted thought processes *CBT assists the client with recognizing distorted thought processes that are maladaptive with regards to recovery. When experiencing mania, the client tends to view the future unrealistically as highly favorable. CBT assists the client in recognizing and challenging such unrealistic or "automatic" thoughts and can help the client and the health care team recognize early trends toward mania

A nurse is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take? A. Address the client in a high pitched voice B. Speak to the client firmly and authoritatively C. Remove potentially harmful objects before leaving the client alone in the room D. Offer the client low-calorie or no-calorie fluids

Speak to the client firmly and authoritatively *Clients who are in a state of panic lose control of their emotions and behavior and feel terror. The nurse must protect the client from any harmful or impulsive behavior, and an authoritative approach can help accomplish this goal

A nurse is caring for a client who has borderline personality disorder (BPD). The client states, "You are the best nurse. All of the other nurses are mean." The nurse should identify that the client is demonstrating which of the following manifestations of BPD? A. Impulsivity B. Clinging C. Splitting D. Manipulation

Splitting *This client is demonstrating the defense mechanism of splitting, which is due to the client's inability to experience both positive and negative emotions at the same time. This inability results in the client's expression of feelings or emotions that are either all good or all bad

A nurse is collecting data from a client who has a history of methamphetamine use. Which of the following findings indicates that the client is currently under the influence of this drug? A. Paranoia B. Slurred speech C. Marked lethargy D. Bradycardia

Paranoia *Acute effects of methamphetamine use include increased heart rate and metabolism, mental alertness, reduced appetite, and paranoia

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the proper use of active listening? A. Offering self B. Using silence C. Paying attention to body language D. Reflecting feelings

Paying attention to body language *Active listening involves identifying verbal and nonverbal communication by the client, which includes paying attention to body language

A nurse is contributing to the plan of care for a 10 year old child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following types of the activities should the nurse include in the plan? A. Checkers B. Chess C. Ping-pong D. Reading

Ping-pong *The nurse should recommend including activities that require repetition and allow the child to get exercise, which can alleviate hyperactivity

A nurse in a mental health unit is contributing to the plan of care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority for this client? A. Promoting and maintaining client safety B. Discussing reasons for the client's behavior C. Helping the client recognize feelings D. Reinforcing teaching with the client about alternative coping strategies

Promoting and maintaining client safety *The nurse should recognize that this client has self-inflicted injuries is at risk of further self-harm or suicide; therefore, the client's safety is the priority.

A home health nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse provide? A. Have the client wear a medical alert necklace B. Place written signs on the bathroom and other doors in the house C. Prevent the client from taking naps during the day D. Provide a low stimulation environment

Provide a low stimulation environment *The nurse should reinforce with the caregiver that clients who suffer from impaired cognition require a low-stimulation environment. An environment of high-stimulation can lead to sensory overload, which can cause increased confusion and anxiety

A nurse is caring for a client with ADHD who has recently started taking lithium. For which of the following findings should the nurse monitor when evaluating the effectiveness of the medication? A. Increased attention span B. Decreased anxiety C. Reduced aggression D. Weight loss

Reduced aggression *Clients who have ADHD can experience a low tolerance for frustration, which can result in aggressive behaviors. Although psychosocial interventions should include developing coping mechanisms and cognitive behavior therapy, the client might require medication to manage aggressive behaviors. The nurse should monitor for reduced aggression when a client who has ADHD is taking a mood stabilizer such as lithium. Additional outcomes of mood-stabilizing medications include decreased impulsivity

A nurse on an acute mental health unit is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following behaviors should the nurse expect? A. Being intentionally dishonest B. Jumping rapidly between topics of conversation C. Tapping the 4 sides of a light switch D. Mimicking the movements of another person

Tapping the 4 sides of a light switch *Tapping the 4 sides of the light switch is an expected behavior for a client who has OCD. Clients with OCD have recurrent and persistent thoughts or urges that are suppressed by performing a compulsion or repetitive behavior

A nurse on a mental health unit is caring for a client who begins throwing objects at other clients. Which of the following actions is the priority nursing intervention? A. Attempt to restrain the client's arms B. Administer an anti-anxiety medication C. Place the client in seclusion D. Tell the client to stop the behavior

Tell the client to stop the behavior *When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should talk to the client to encourage her to calm down and prevent harm to others

A nurse is collecting data from a toddler who has a fractured arm. Which of the following findings should the nurse identify as a possible indication of physical abuse? A. The parent provides a history that is inconsistent with the child's injury B. The child is brought to the health care facility immediately following the injury C. The parent requests to remain present with the child throughout treatment of the injury D. The child clings to the parent when the nurse begins to examine the injury

The parent provides a history that is inconsistent with the child's injury *The nurse should suspect possible abuse when the child's injury conflicts with the history of the injury reported by the parent

A nurse in a mental health facility is meeting with a client who has a diagnosis of major depression. During the conversation, the client stops speaking, and the nurse sits silently next to the client for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the following purposes? A. To show approval of the client's desire not to talk B. To give the client time to evaluate the nurse C. To encourage the client to express feelings or concerns D. To prevent the nurse from offering a nontherapeutic response

To encourage the client to express feelings or concerns *Silence during therapeutic communication has many functions, including providing clients with time to formulate their thoughts and encouraging the expression of feelings or concerns that they wish to discuss. During silence, the client can also consider alternatives and think about what has been said

A nurse is caring for a client who has a repetitive tic that is accompanied by rapid blinking. The client occasionally repeats phrases spoken by others. The nurse should identify that these findings are an indication of which of the following disorders? A. Autism spectrum disorder B. Attention deficit hyperactivity disorder C. Oppositional defiant disorder D. Tourette's disorder

Tourette's disorder *The nurse should suspect that this client has Tourette's disorder, which can include more than 1 motor tic along with vocal tics (e.g. repeating phrases of others or barking.)

A nurse in a rehabilitation center is collecting data from a client who is being admitted for alcohol use disorder. The client states, "My last drink was 8 hours ago." Which of the following manifestation indicates that the client is experiencing withdrawal from alcohol? A. Sleepiness B. Tremors C. Hypothermia D. Diarrhea

Tremors *A client who has alcohol use disorder can experience manifestations of withdrawal within 6 to 8 hours following their last drink. The classic sign of withdrawal is mild tremors. Other manifestations of withdrawal agitation, lack of appetite, nausea, insomnia, impaired cognition, hypertension, tachycardia, and hyperthermia

A nurse is reinforcing teaching with the guardian of a client who has bipolar disorder and a new prescription for olanzapine. Which of the following adverse effects should the nurse instruct the guardian to report to the provider? A. Hypertension B. Tremors C. Ringing in the ears D. Pain with urination

Tremors *Olanzapine can cause extrapyramidal symptoms (EPS). The nurse should reinforce with the guardian to report manifestations indicating the development of EPS such as bradykinesia, mask-like facies, tremors, rigidity, a shuffling gait, drooling, stopped posture, or spasm of the muscles of the tongue, face, neck, or back

A nurse is assisting with the admission of a client who has tetraplegia. The nurse notes multiple bruises on the client and suspects abuse. Which of the following actions should the nurse take? A. Interview the client with the caregiver present B. Inform the provider that the caregiver is to blame for the abuse C. Begin the interview with simple close-ended questions D. Inform the client that nurses are required to notify protective services

Inform the client that nurses are required to notify protective services *The nurse should inform the client that nurses are required to report indications of abuse to protective services. An investigation will be performed to ensure the client's safety

A nurse is collecting data from a newly admitted client. To establish trust, which of the following actions should the nurse perform during the orientation phase of the nurse-client relationship? A. Inform the client that the admission is confidential B. Introduce the client to other clients in the dayroom C. Assist the client with facilitating behavioral change D. Determine coping strategies that the client has used in the past

Inform the client that the admission is confidential *According to evidence-based practice, the nurse should inform the client about confidentiality during the orientation phase of the nurse-client relationship. This action helps establish trust between the nurse and the client

A nurse is caring for a client who was admitted to the mental health unit for substance use disorder. The client states, "I am a nurse on the medical-surgical floor, and I don't want my coworkers to know I have been diverting drugs." Which of the following actions should the nurse take? A. Advise the client that her supervisor will be transferring her to another unit following treatment B. Inform the client that the information will be shared with the treatment team C. Explain to the client that there is a legal obligation to inform coworkers of her actions D. Tell the client her coworkers' opinion should not matter

Inform the client that the information will be shared with the treatment team *It is the nurse's legal duty to maintain the client's confidentiality. Only members of the client's treatment team should receive information about her medical history and care

A nurse is caring for a client who is receiving care at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort? A. Administering an incorrect dose of benzodiazepine B. Informing the client's family member of the admission without the client's knowledge C. Informing the client that an injection will be administered if the client remains agitated D. Failing to recognize suicide risks, which results in the client's death

Informing the client that an injection will be administered if the client remains agitated *This is an example of assault. Assault is an intentional tort that is characterized by a threat toward a client that makes the client fearful of harm or unwanted touching

A nurse is caring for a client who has bipolar disorder and is experiencing hypomania. During a conversation with other clients, she becomes agitated and begins speaking in a loud, angry voice. Which of the following actions should the nurse take? A. Invite the client to take a walk B. Reprimand the client for her rude behavior C. Point out inappropriate behaviors to the client D. Administer trazodone to the client

Invite the client to take a walk *The client's increasing agitation demonstrates a potential for violent behavior. To maintain a safe environment, the nurse should remove the client from the situation and disperse her anger by walking and talking with her

A nurse is reinforcing teaching about stress management with a client who is experiencing anxiety. Which of the following techniques should the nurse recommend to assist the client in identifying his stressors? A. Biofeedback B. Intellectualization C. Journaling D. Cognitive reframing

Journaling *Journaling is a technique that can be used to identify stressors. By recording feelings and responses to events, the client can find the source of everyday stressors and begin the process of stress reduction

A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? A. Withhold PRN anti-anxiety medication B. Provide the client with a stimulating activity prior to bedtime C. Keep the client's room well-lit at night D. Encourage the client to make decisions about her daily routine

Keep the client's room well-lit at night *The nurse should keep the client's room well-lit. Adequate lighting can help her remain oriented to place upon waking at night and will promote safety if she becomes ambulatory

A home health nurse is collecting data from a client who has advanced dementia and whose caretake recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse recommend a referral for this client? A. Partial hospitalization B. Adult daycare facility C. Inpatient geropsychiatric unit D. Long-term nursing care center

Long-term nursing care center *A long term care nursing center provides intermediate or custodial care for clients who have acute or chronic illnesses. A client who has advanced dementia is a candidate for a skilled nursing facility because the client needs 24 hour nursing care and support

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal psychosis. Which of the following medications should the nurse prepare to administer? A. Lorazepam B. Methadone C. Thiamine D. Haloperidol

Lorazepam *Alcohol withdrawal psychosis can begin within g8 to 10 hours following alcohol cessation and is a medical emergency because it can lead to unconsciousness, seizures, or delirium. The nurse should prepare to administer the benzodiazepine lorazepam, which can be given by mouth or intramuscularly

A nurse is assisting with the care of a client who is experiencing acute alcohol withdrawal. Which of the following medication should the nurse prepare to administer? A. Carbamazepine B. Clonidine C. Propranolol D. Lorazepam

Lorazepam *The nurse should expect to administer lorazepam, a benzodiazepine, as the first treatment for acute alcohol withdrawal. Along with decreasing symptoms of acute alcohol withdrawal, these medications can also maintain vital signs and prevent seizures and delirium tremens

A nurse is collecting data from an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use? A. Avoid directly asking the client if she has been abused B. Use a confrontational speech C. Maintain a nonjudgmental tone D. Avoid being in the room alone with the client

Maintain a nonjudgmental tone *The nurse should use a nonjudgmental tone to promote trust and communication

A nurse is preparing to interview a client who has generalized anxiety disorder. Which of the following actions should the nurse take? A. Set the pace of the interview B. Place the chairs across from each other C. Position the chairs 1.2 m (4 ft) apart D. Maintain an open posture during the interview

Maintain an open posture during the interview *The nurse should be mindful of nonverbal cues such as eye contact, facial expressions, and posture. Maintaining an open posture conveys openness to what the client is saying, while a closed posture with arms crossed can make the client feel defensive

A nurse is contributing to the plan of care for a client who has borderline personality disorder and self-mutilates. Which of the following treatment approaches should the nurse recommend? A. Restrict participation in group therapy sessions B. Establish consequences for self-mutilation C. Maintain close observation of the client D. Provide an unstructured environment

Maintain close observation of the client *Clients who have borderline personality disorder are at risk of self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury

A nurse is caring for a client who has generalized anxiety disorder (GAD). Which of the following goals should the nurse include in the discharge plan of care for this client? A. Use whistling or singing as a distraction to control hallucinations B. Make independent decisions about daily events C. Verbalize a realistic perception of personal appearance D. Decrease the use of ritualistic behavior

Make independent decisions about daily events *A client who has GAD demonstrates indecisiveness and has unrealistic and persistent anxiety most days of the week. This can cause the client to avoid situations that produce anxiety or to procrastinate necessary decision-making. The ability to make independent decisions about daily events is a goal the nurse should include in the discharge plan of care for the client

A nurse working in a retirement community is collecting data from an older adult client. Which of the following manifestations should the nurse identify as an expected age-related change? A. Making occasional errors when balancing a checkbook B. Confusion with time or place C. Poor judgment D. Changes in mood

Making occasional errors when balancing a checkbook *The nurse should identify that making occasional errors when balancing a checkbook is an expected age-related change in an older adult. Other manifestations can include needing occasional assistance with operating appliances, forgetting a name or an appointment and then remembering it later, difficulty finding the correct use of a word, and becoming tired after social activities

A nurse in a provider's office is collecting data for a client who has been taking donepezil for Alzheimer's disease. The data indicate that the client's disease is progressing and becoming more severe. Which of the following medications should the nurse expect the provider to prescribe? A. Megestrol B. Galantamine C. Memantine D. Haloperidol

Memantine *As Alzheimer's disease progresses and becomes more severe, memantine is added to the medication regimen. The medication is an n-methyl-D-aspartate antagonist, which can enhance cognition. It does not cure Alzheimer's disease

A nurse in a rehabilitation center is planning to reinforce medication teaching with a client who is being discharged following treatment for opioid use disorder. Which of the following medications should then nurse expect the provider to prescribe for the client? A. Diazepam B. Disulfiram C. Bupropion D. Methadone

Methadone *Methadone is used to decrease symptoms during the withdrawal phase of opioids. It is also used following withdrawal for maintenance therapy, as methadone decreases the euphoric effects of opiate drugs. Methadone can also lead to dependence, and the client will eventually need to be withdrawn from the medication

A nurse is helping a client who has anxiety disorder select a nonpharmacological stress-reduction therapy for home use. Which of the following therapies engages the insular cortex of the brain to allow the client to focus on a single thought that is important to the client in the present moment? A. Guided imagery B. Progressive relaxation C. Cognitive reframing D. Mindfulness

Mindfulness *The practice of mindfulness engages the insular cortex as the person focuses on the sensations and surroundings of the present moment. The client learns to stop the mind from wandering to multiple thoughts and worries and to concentrate on a single thought or situation that is important at that time

A nurse working in a retirement community is collecting data from an adult client. Which of the following findings should cause the nurse to suspect the client is experiencing the early stages of Alzheimer's disease? A. Requiring help to record a television show B. Misplacing a family heirloom C. Feeling tired after a social gathering D. Completing tasks in a particular way

Misplacing a family heirloom *The nurse should identify that misplacing a valuable object such as a family heirloom occurs in the early stages of Alzheimer's disease. The nurse should continue to gather more information from the client and speak with the client's provider about the findings

A nurse is caring for a client who was just admitted for treatment of anorexia nervosa. Which of the following actions should the nurse take? A. Discuss the nutritional value of foods during meal times B. Weight the client 3 mornings per week C. Allow the client to exercise for up to 1 hour per day D. Monitor the client for 1 hour following meals and snacks

Monitor the client for 1 hour following meals and snacks *The nurse should monitor the client after eating meals and snacks to prevent purging

A nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take? A. Monitor the client's liver function B. Avoid giving the medication with food or milk C. Counsel the client regarding medication dependency D. Limit intake of foods containing tyramine

Monitor the client's liver function *Valproic acid can cause severe hepatotoxicity and liver failure. The nurse should monitor the client's liver function at baseline and periodically thereafter. The nurse should also teach the client about the manifestations of liver failure

A nurse is caring for a child who has Tourette's disorder. Which of the following behaviors should the nurse expect? A. Multiple motor and vocal tics B. Areas of baldness on the scalp C. Insatiable hunger D. Exaggerated startle response

Multiple motor and vocal tics *The nurse should expect a child who has Tourette's disorder to display multiple motor and vocal tics. A tic is a sudden physical movement or vocalizations of sounds or words that are unrelated to the topic of conversation. Tics can change in frequency, severity, and location. Tourette's disorder is an inherited condition that causes clients to have multiple physical and 1 or more vocal tics

A nurse is assisting with planning care for a client who has completed detoxification from opioid abuse disorder. The nurse should plan to teach about which of the following medications? A. Methadone B. Naltrexone C. Buprenorphine D. Disulfiram

Naltrexone *The nurse should plan to educate the client on the medication naltrexone, an opioid antagonist that is used for the long-term maintenance of opioid use disorder. Naltrexone is the usual medication choice following detoxification from opioids

A nurse is caring for a client in a mental health facility and overhears the client discussing plans to harm her father-in-law physically when she is discharged. Which of the following interventions should the nurse take? A. Ask the client to sign a contract agreeing not to harm others B. Notify the provider of the client's threat C. Keep the client's discussion confidential D. Place the client in individual observation

Notify the provider of the client's threat *It is the nurse's duty to notify the provider of the client's threat. It will then be the provider's responsibility to warn the the intended victim or the police of the client's threat

A nurse is assisting with the care of a client who has a substance use disorder and was involuntarily admitted by court order for 90 days. When the nurse attempts to administer prescribed oral lorazepam to decrease the client's manifestations of withdrawal, the client aggressively refuses. Which of the following actions should the nurse take? A. Place the lorazepam on hold B. Request a prescription for IM lorazepam C. Request that another nurse attempt to administer the lorazepam D. Place the lorazepam in the client's food

Place the lorazepam on hold *Clients who are in a health care facility due to an involuntarily admission retain the right to refuse treatment, including prescribed medications. Therefore, the nurse should hold the medication, document the client's wishes in the medical record, and notify the provider of the refusal

A nurse is collecting data from a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? A. Positive B. Cognitive C. Negative D. Affective

Positive *The nurse should identify a client who has schizophrenia and is experiencing delusions is demonstrating a positive symptom. Positive symptoms are seen early in clients who have schizophrenia and are easier to detect that other types of symptoms. Other positive symptoms can include hallucinations, disorganized speech, and disorganized behavior

A nurse at a long term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? A. Encourage the client to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place a wander alert electronic alarm bracelet on the client's wrist

Post a large calendar on the bulletin board *Posting a large calendar in a central location will assist the client with orientation

A nurse is reviewing laboratory reports of a client who has anorexia and is malnourished. Which of the following results should the nurse report to the provider immediately? A. Potassium 2.9 mEq/L B. Hemoglobin 10 g/dL C. Creatinine 0.5 mg/dL D. Sodium 136 mEq/L

Potassium 2.9 mEq/L *When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is potassium level of 2.9 mEq/L. The expected reference range for potassium is 3.5-5 mEq/L, with critical levels of less than 3 or greater that 6.1 mEq/L. A client who has a critical level of potassium is at great risk for cardiac dysrhythmias

A nurse is reviewing discipline techniques with the parents of an adolescent client who has oppositional defiant disorder. Which of the following techniques should the nurse recommend as an effective method of responding to the adolescent? A. Offering frequent physical touching B. Allowing self-regulation of boundaries C. Practicing planned ignoring D. Giving negative feedback

Practicing planned ignoring *Planned ignoring is an appropriate means of responding to clients who have oppositional defiant disorder. The nurse should reinforce the use of this technique with the parents as a response to the client's attention-seeking behaviors

A nurse is caring for a client with anorexia nervosa who has light skin. Which of the following findings should the nurse expect? A. Presence of lanugo B. Flushed skin tone C. Hyperactive bowel sounds D. Clubbing of the fingernails

Presence of lanugo *The nurse should expect a client who has anorexia nervosa to have lanugo (fine, neonatal-like hair growth) on the body as a result of malnutrition and starvation

A nurse is assisting with the plan of care for a client who has vegetative signs of depression. Which of the following actions should the nurse include in the plan? A. Limit snacking between meals B. Schedule regular naptimes during the day C. Weigh the client monthly D. Provide decaffeinated beverages

Provide decaffeinated beverages *A client who has vegetative signs of depression is at high risk for altered sleep. Because caffeinated beverages can interrupt restful sleep, the nurse should plan to offer the client decaffeinated beverages

A nurse in an acute mental health facility is participating in a group therapy session in which client enact situations to help them process past events. The nurse should identify that which of the following types of group therapy is being carried out? A. Psychoeducational group B. Psychodrama group C. Family therapy group D. Self-help group

Psychodrama group *In a psychodrama group, members actually take parts and act out a client's past experiences in the present time. This experience allows a client to process and gain insight into past experiences that present significant emotional issues

A nurse is reinforcing teaching with a client who has a new disulfiram prescription for the management of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to avoid? A. Peppermint candy B. Pure vanilla extract C. Salt D. Chocolate

Pure vanilla extract *The nurse should instruct the client to avoid alcohol-containing substances such as pure vanilla extract while taking disulfiram. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension

A nurse is caring for a client who has a neurocognitive disorder and wanders at night. Which of the following actions should the nurse take to promote the client's safety? A. Put the client's mattress on the floor B. Keep the lights off in the client's room at night C. Limit snacks during the evening hours D. Turn off the client's radio or music player at night

Put the client's mattress on the floor *This action reduces the client's risk of injury from falling out of bed when confused or getting up to wander

A nurse is caring for a client who is showing evidence of addiction to pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, "It is not an illegal drug." Which of the following defense mechanisms is the client using? A. Displacement B. Rationalization C. Projection D. Sublimation

Rationalization *Rationalization is the justification of unacceptable behavior by offering acceptable explanation. This is also known as making excuses

A nurse is caring for a client who has generalized anxiety disorder. The client states, "I am so stressed about my work and finances. I can't think straight anymore." Which of the following actions should the nurse take first? A. Administer antianxiety medication B. Speak slowly and calmly C. Remain with the client D. Ask the client to talk about preceding events

Remain with the client *The greatest risk to this client is an injury from anxiety and distress, which can cause the client to lose control. Therefore, the nurse should remain with the client to convey acceptance and promote security

A nurse is collecting data from a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Arthralgia B. Photophobia C. Xerostomia D. Bradycardia

Xerostomia *Buspirone can cause xerostomia, or dry mouth. Other adverse effects include headache, nausea, and insomnia

A nurse is reinforcing dietary teaching with a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which of the following food selections by the client indicates an understanding of the teaching? A. Cheddar cheese B. Avocados C. Pepperoni D. Yogurt

Yogurt *Yogurt does not contain high amounts of tyramine and is allowed for clients who are taking an MAOI medication

A nurse is assisting with the plan of care for a client who is scheduled for electroconvulsive therapy (ECT). Which of the following interventions should the nurse add to the plan of care for this client? A. Maintain a clear liquid diet for 6 to hours prior to ECT B. Allow the client to sleep for 3 to 4 hours following ECT C. Administer IM epinephrine to the client prior to ECT D. Reorient the client to the environment after ECT

Reorient the client to the environment after ECT *Due to a transient period of confusion after the ECT, the nurse should plan to reorient the client

A nurse is collecting data from a client prior to the administration of lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4 lb) since the start of treatment C. Fine tremors present in both hands D. Serum lithium level of 1.1 mEq/L

Report of nausea with frequent episodes of emesis *The nurse should identify that gastrointestinal upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. The nurse should check the client for indications of dehydration, which further increases the risk of lithium toxicity

A nurse in a health clinic is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and sends the client home. Which of the following actions should the nurse take? A. Request a social services consultation B. Contact the child's guardian to discuss the suspicion C. Report the provider's actions to the state medical board D. Report the suspected abuse to law enforcement

Report the suspected abuse to law enforcement *Nurses are legally mandated to report suspected child and vulnerable adult abuse. The nurse should report the suspected child abuse to the appropriate agency of the state in which she is practicing.

A nurse is assisting with monitoring a client who ingested an overdose of pentobarbital sodium. For which of the following adverse effects of toxicity should the nurse assess the client? A. Cerebrovascular accident B. Dysrhythmias C. Liver failure D. Respiratory depression

Respiratory depression *Pentobarbital is a barbiturate that is used for seizure disorders, induction of anesthesia, insomnia, and acute manic states and delirium. The most dangerous adverse effect of the medication is respiratory depression that can be fatal

A nurse on an inpatient rehabilitation unit is assessing a client who has a history of opioid use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect? A. Hyperactivity B. Headache C. Rhinorrhea D. Tremulousness

Rhinorrhea *Rhinorrhea, lacrimation, pupillary dilation, yawning, and piloerection are classic manifestations of opioid withdrawal

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following clinical manifestations should the nurse expect? A. Sedation B. Rhinorrhea C. Bradycardia D. Hypothermia

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

A nurse is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse recommend including in the plan? A. Schedule specific times for the client to eat B. Compromise about foods the client is willing to eat C. Focus on the client's weight gain goal D. Weigh the child at the same time every week

Schedule specific times for the client to eat *The nurse should recommend scheduling specific meal times for the client. Mealtime can be stressful for clients who have anorexia nervosa, and this allows them time to prepare

A nurse is reinforcing teaching with a client who has panic disorder and a new prescription for clomipramine. Which of the following adverse effects should the nurse include in the teaching? A. Diarrhea B. Sedation C. Hypertension D. Urinary frequency

Sedation *The nurse should inform the client that adverse effects of clomipramine include sedation, orthostatic hypotension, and anticholinergic effects such as dry mouth, blurred vision, urinary retention, constipation, and tachycardia

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. Impaired memory C. Dysphoria D. Social discomfort

Social discomfort *The absence of something that should be present is considered a negative symptom of schizophrenia. Social discomfort, the inability to enjoy activities, or a lack of goal-directed behavior are negative symptoms of schizophrenia

A nurse on a mental health unit is planning care for a client who has anorexia nervosa with purging behaviors. Which of the following interventions should the nurse include in the plan? A. Set the client's weight gain at 2.3 kg (5 lb) per week B. Allow the client to establish his own mealtimes C. Stay with the client for 1 hour following meals D. Have the client weigh himself daily

Stay with the client for 1 hour following meals *The nurse should plan to stay with and observe the client for 1 hour following each meal to discourage the client from hiding food or purging by self-induced vomiting

A nurse is collecting admission data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? A. Poor personal hygiene habits B. Strenuous exercise regimen C. Grandiose behaviors D. Intense fear of death

Strenuous exercise regimen *The nurse should expect a client who has anorexia nervosa to repost a strenuous exercise regimen. The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight

A home health nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse why the client becomes disoriented, confused, and often combative later in the day. For which of the following conditions should the nurse plan to gather more information? A. Electrolyte imbalance B. Hypothyroidism C. Sundowning D. Adverse effect of medication

Sundowning *Sundowning-an increase in confusion beginning in the afternoon and lasting into the night-is a common manifestation of Alzheimer's disease. The client can become confused, aggressive, agitated, and obsessive, leading to severe disorientation

A nurse is discussing the benefits of group therapy with a client who has bipolar disorder. The nurse should identify which of the following as an advantage of this form of treatment? A. Decreased pressure from others to engage in unacceptable behaviors B. The chance to learn from the experiences of other individuals C. An outlet for increased energy during episodes of mania D. The opportunity to have increased participation time during therapy

The chance to learn from the experiences of other individuals *The nurse should identify the opportunity to learn and gain insight from other group members as an advantage of group therapy

A nurse on a pediatric mental health unit is receiving reports on 4 children. Which of the following reports should the nurse expect for a child who has an autism spectrum disorder? A. The child cannot sit still to be read to B. The child displays neck jerking tics C. The child has a ritualized behavior pattern D. The child bullies the other children on the unit

The child has a ritualized behavior pattern *Children who have autism spectrum disorder often display ritualized behavior patterns to the point of being inflexible with changes in routines. Minor changes to established routines can cause the child to become agitated

A nurse in a provider's office is reviewing the medical history of a client who asks about the use of varenicline for smoking cessation. Which of the following items in the client's medical history indicates a precaution for the use of varenicline? A. The client has type 1 diabetes mellitus B. The client has a history of depression C. The client has rheumatoid arthritis D. The client has a history of GERD

The client has a history of depression *The nurse should recognize that varenicline can cause mood changes and thoughts of suicide. Precautions should be taken when prescribing this medication to clients who have a history of psychiatric disease such as depression

A nurse on a mental health unit is caring for a client who is displaying signs of anger. Which of the following pieces of information about the client is the strongest indicator that the client might become aggressive? A. The client has marginal coping skills B. The client has a history of violence C. The client feels powerless after being hospitalized D. The client blames others for her problems

The client has a history of violence *The client's history of violence is the most important indicator that this client might become violent; therefore, this is the strongest indicator of potential aggressiveness.

A nurse in a provider's office is collecting data from a client who has been taking varenicline. Which of the following reports from the client indicate a therapeutic response to the medication? A. The client is taking fewer opioid pain relievers B. The client no longer has delirium tremens C. The client has reduced cravings for cigarettes D. The client is less hyperactive

The client has reduced cravings for cigarettes *Varenicline is prescribed for the treatment of tobacco use disorder. A therapeutic response to the medication is a decrease in cravings for nicotine. Other medications prescribed for this disorder include bupropion and clinidine

A nurse in a mental health clinic is caring for a client who has anxiety disorder related to post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates a therapeutic response to treatment? A. The client spends most of the day in bed B. The client prefers to talk about things other than his anxiety C. The client seeks out environments with increased stimuli D. The client identifies situations that cause anxiousness

The client identifies situations that cause anxiousness *The client's ability to identify situations that lead to episodes of anxiety is an indication of a therapeutic response to treatment. If the client can foresee and prepare for these situations, the client will have a better chance of controlling emotions

A nurse is collecting data from a client who lost his mother a few months ago and is feeling depressed. Which of the following findings should cause the nurse to suspect the client has major depressive disorder? A. The client focuses on reuniting with his mother B. The client is unable to express pleasure C. The client reports feeling anger D. The client reports experiencing intense sadness

The client is unable to express pleasure *The client's inability to express pleasure is a manifestation of major depressive disorder. Other manifestations include decreased energy, depressed mood for most of the day, thoughts of death, being self-critical, and inappropriate guilt

A nurse is collecting data from a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamines? A. The client exhibits paranoia B. The client reports having insomnia C. The client reports eating excessively D. The client has an increased heart rate

The client reports eating excessively *When amphetamine is taken at a therapeutic dose, it causes appetite suppression. Abrupt withdrawal of amphetamine can result in abstinence syndrome in a client who is physically dependent on the medication. Indications of physical dependence include excessive eating, exhaustion, depression, prolonged sleep, and a craving for more amphetamine

A nurse is collecting data from a client who has bipolar disorder and is in maniac state. Which of the followings is the highest priority? A. The client reports sleeping 2 to 3 hours per night B. The client speaks to the nurse in a demanding tone C. The client reports not attending group therapy D. The client reports not taking medication for the past 2 weeks

The client reports sleeping 2 to 3 hours per night *The greatest risk to this client is an injury from exhaustion due to lack of sleep; therefore, the priority is the client's report of decreasing sleep time

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? A. The death was a result of violence B. The client expresses anger over the loss C. This is the client's first experience of the loss of a family member D. The client demonstrates reorganization of behavior

The death was a result of violence *When death is a result of violence, is traumatic, or is unexpected, the loss can result in maladaptive grieving for those left behind. This type of grief is complicated by the survivors not having an opportunity to prepare for the death or to say goodbye

A nurse is admitting a client who has derealization disorder. Which of the following manifestations should the nurse expect? A. The inability to recall important personal information B. The feeling that the surroundings are unreal C. The inability to recall identity D. The presence of at least 2 distinct personalities

The feeling that the surroundings are unreal *The feeling that the surroundings are unreal or distant is a manifestation of derealization disorder. Clients who have this disorder might feel mechanical, dreamy, or detached from their body. Often, the manifestations are destressing and come and go. The disorder occurs as a response to acute stress

A nurse is collecting data from an adult client whose sister recently died in a motor vehicle crash. The nurse should identify that which of the following factors indicates an increased risk for a complicated grief reaction? A. The loss of a sibling B. The perception that the death was unavoidable C. The sudden occurrence of the death D. The presence of a social support network

The sudden occurrence of the death *A sudden, unanticipated death can complicate the mourning process and lead to a complicated grief reaction. Other factors include death from a lengthy illness, the loss of a child, or the perception that the death was preventable

A nurse is reinforcing teaching with a client who wants to stop smoking by using nicotine gum. The nurse should inform the client that which of the following adverse effects can occur from using nicotine gum? A. Itching B. Throat irritation C. Hiccups D. Teary eyes

Throat irritation *The nurse should instruct the client that throat irritation is an adverse effect of chewing nicotine gum. Other adverse effects include mouth irritation, aching jaw muscles, and dyspepsia

A nurse is collecting data from a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline? A. Disorientation to time B. Problems handling finances C. Social withdrawal D. Impaired recent memory

Impaired recent memory *Short-term memory loss is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality

A client who has hypertension presents to a provider's office. When speaking with the nurse, she reports a considerable amount of stress at work and states it is affecting her blood-pressure control. The nurse should instruct the client to do which of the following when the stress is unavoidable? A. Consider changing jobs to something less stressful B. Identify the stressors at work and try to reduce them C. Plan periods away from work throughout the day D. Improve her ability to cope with identified stressors

Improve her ability to cope with identified stressors *The nurse should help the client learn management techniques to deal with stress without internalizing it

A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as negative symptoms? A. Hallucinations B. Inability to experience pleasure C. Disorganized speech D. Unusual behavior

Inability to experience pleasure *The inability to experience pleasure is a negative symptom of schizophrenia. Negative symptoms of schizophrenia are more difficult to detect. Other negative symptoms can include a lack of motivation, a blunt affect, a lack of interest, and a reduction speech

A nurse is teaching a client who has bipolar disorder and a new prescription for lithium. The nurse should identify that which of the following statements by the client indicates an understand of the teaching? A. "I should take my lithium on an empty stomach." B. "I can take ibuprofen for headaches while taking lithium." C. "I need to limit my salt intake while taking lithium." D. "I am likely to gain weight while taking lithium."

"I am likely to gain weight while taking lithium." *The nurse should instruct the client about eating a low-calorie diet while taking lithium because this medication can cause weight gain

A nurse is talking with the partner of a client who has alcohol use disorder. Which of the following statements by the client's partner should the nurse identify as an indication of codependence? A. "My partner is addicted to both alcohol and cocaine." B. "I have an alcohol problem just like my partner does." C. "My partner only drinks to deal with her major depression." D. "I call my partner's boss when she's had too much to drink to go to work."

"I call my partner's boss when she's had too much to drink to go to work." *The nurse should identify this statement as an indication of codependency in which the codependent individual takes on extra responsibilities and assists the client who has the alcohol use disorder in meeting obligations. This caregiving affects the individual's perception of self-worth and can cause the individual to put the needs of the client first

A nurse is collecting data from a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief? A. "I wish I had been nicer and more generous to my wife before she died." B. "I told my wife to go to the doctor, but she wouldn't listen to me." C. "I think about my wife all the time when I go on outings with my family." D. "I feel so empty without my wife that it's hard to get up every morning."

"I feel so empty without my wife that it's hard to get up every morning." *The nurse should identify that a client who has difficulty performing normal activities following the loss of a partner is at risk for complicated grief

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements should the nurse make? A. "Limit daytime napping to an hour maximum." B. "Watch TV as you fall asleep." C. "If you aren't able to sleep, you can get out of bed and read a book." D. "Track the number of hours that you sleep each night."

"If you aren't able to sleep, you can get out of bed and read a book." *The nurse should instruct the client to get of bed and participate in a quiet activity such as reading until he feels sleepy, at which time he should return to bed.

A nurse is caring for a client who has obsessive-compulsive disorder and feels that pacing the floor for a specific number of times is necessary or else "something bad will happen." Which of the following responses should the nurse provide? A. "Nothing terrible is going to happen to you. Please stop this behavior." B. "Are you seeking attention with this behavior?" C. "It may help if we talked about why you find it necessary to pace the floor." D. "Are you pacing to work off excess energy?"

"It may help if we talked about why you find it necessary to pace the floor." *This response is therapeutic and encourages the client to discuss the underlying thoughts and feelings that are causing anxiety

A nurse is reinforcing teaching with the caregiver of a child who has pica. Which of the following statements should the nurse identify as an indication that the caregiver understands the teaching? A. "My child will have this disorder for the rest of his life. B. "My child will return undigested food to his mouth because of this disorder." C. "My child might try to eat dirt when we are at the playground." D. "My child will need to be repositioned during feedings."

"My child might try to eat dirt when we are at the playground." *Pica is the persistent eating of non-food substances that have no nutritional value such as dirt or paint

A nurse is collecting data from a client who was in a motor-vehicle crash that killed her sibling. The client is shaking and asks, "What can I do now?" Which of the following questions is the nurse's priority? A. "Are you thinking about hurting yourself?" B. "Do you have someone who could come here to be with you?" C. "How will this situation affect your life?" D. "What qualities have helped you cope with a crisis in the past?"

"Are you thinking about hurting yourself?" *The client's statement and current emotional state indicate that the client's greatest risk for self-harm. Therefore, the priority for the nurse is to ask the client about the possibility of suicide or self harm

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired, is an important part of your treatment." B. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." D. "I agree with your decision to wait for participation in group therapy until you begin to feel better."

"Attending group therapy, even if you're tired, is an important part of your treatment." *Through this therapeutic response, the nurse is giving the client information to make an informed decision. Group therapy benefits clients who have depression by promoting peer support and reducing social isolation

A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates clang associations? A. "I am the king, and everyone should bow to me." B. "I'm feeling schmoolizious today." C. "Option, contrary, moose, allergic." D. "Basketball in the hall very tall.

"Basketball in the hall very tall. *A client who speaks using clang associations is choosing words based on their sound rather than meaning

A nurse is reinforcing teaching with a client who has an anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make? A. "Schedule 20 minutes of aerobic exercise during the hour before bedtime." B. "Eliminate all caffeinated beverages from your diet." C. "Sleep for extra time when you can." D. "Eat a light snack containing carbohydrates before bedtime."

"Eat a light snack containing carbohydrates before bedtime." *A light snack consisting of a carbohydrate-based food or milk can help promote sleep when ingested before bedtime. Consuming heavy meals just before sleeping can promote insomnia

A nurse is discussing family therapy with a client. Which of the following statements by the nurse is therapeutic? A. "Family therapy helped my family." B. "I need to sign you up for family therapy." C. "Family therapy can bring about change." D. "Why do you think you need family therapy?"

"Family therapy can bring about change." *The nurse is using the therapeutic communication technique of providing information. By explaining what family therapy can offer, the nurse can empower the client to make a better decision about whether to pursue such therapy

A nurse is interviewing a client whose partner died 6 months ago. The client states, "I feel so lonely and empty inside." Which of the following responses should the nurse make? A. "I know how you feel." B. "Have you thought about remarrying?" C. "This loss must be tragic for you." D. "Your partner is in a better place now."

"This loss must be tragic for you." *The nurse should respond by restating how the client feels and allowing the client to express feelings about the loss

A nurse is providing support for a client who is grieving the loss of her mother who died from Alzeimer's disease. Which of the following statements should the nurse offer? A. "I know how you must be feeling. I recently lost my father." B. "Dealing with your mother's death must be difficult for you." C. "Knowing your mother is in a better place provides you with some comfort." D. "I want you to let me know what I can do to help you cope with your mother's death."

"Dealing with your mother's death must be difficult for you." *The nurse should use therapeutic communication when supporting a client who is grieving. This statement keeps the focus of the conversation on the client by acknowledging her grief and encourages further communication."

A nurse is reinforcing teaching with a family member of a client who has dementia. Which of the following statements should the nurse include? A. "Dementia is often associated with a reaction to a new medication." B. "Dementia is usually reversible with prompt treatment." C. "Dementia develops rapidly over a matter of hours or days." D. "Dementia is commonly associated with Alzheimer's disease."

"Dementia is commonly associated with Alzheimer's disease." *The nurse should identify the common causes of dementia, which include Alzheimer's disease, chronic alcohol use disorder, diseases affecting the neurological and vascular systems, and head trauma

A nurse in a mental health clinic is caring for a client who is grieving over the sudden death of his child. Which of the following statements should the nurse offer? A. "Be grateful for the time you had with your child." B. "I know you are glad your child didn't suffer." C. "You are young and can have more children." D. "I cannot imagine how you are feeling right now."

"I cannot imagine how you are feeling right now." *The nurse should allow the client to express his feelings and talk about emotions without telling the client how to feel or diminishing the client's grief. This therapeutic response by the nurse by the nurse allows the client to express grief while providing the opportunity for further communication

A nurse is reinforcing teaching with a client who has acrophobia about the use of systemic desensitization as a method of behavioral therapy. Which of the following client statements indicates an understanding of the teaching? A. "I will snap a rubber band on my wrist when heights scare me." B. "I will slowly be exposed to places of increasing height." C. "I will need to stand on a very high place until I'm calm." D. "I will be asked to imitate how my therapist acts around heights."

"I will slowly be exposed to places of increasing height." *This statement indicates client understanding of systematic desensitization. This form of behavioral therapy gradually exposes the client to frightening places or situations and teaches the client to overcome the fear through the use of relaxation techniques

A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kubler-Ross' stages of grief? A. "I would give anything to live to see my grandchildren born." B. "Can you make sure there hasn't been a mistake with my test results." C. "I feel so sad that I will be leaving my partner all alone." D. "What have I done to deserve this death sentence?"

"I would give anything to live to see my grandchildren born." *Kubler-Ross identified common responses of clients who experience any form of loss. These responses are divided into 5 stages. While each of these stages is experienced by clients, they are not necessarily experienced in a linear fashion or in the exact same order. Some clients can experience a stage more than once. This response shows that the client is in the bargaining stage and might be trying to make a deal with a higher power to prolong life

A nurse is assisting with the care of a client who has a terminal illness. The client yells at the nurse, "Get out of my sight. You've always bothering me about something!" Which of the following responses should the nurse offer? A. "You don't have to yell. I'm sorry you feel like I've bothered you." B. "I'll go, but I'll be back in a little while when you have calmed down." C. "I'm going to have to ask you to be quieter since there are other clients on this unit." D. "I'll be here if you would like to talk about how you feel."

"I'll be here if you would like to talk about how you feel." *This response by the nurse acknowledge the client's feelings and provides a mechanism for further conversation, which helps create and maintain a therapeutic relationship between the nurse and the client

A nurse is reinforcing teaching with a client who has a prescription for a tricyclic antidepressant. Which of the following instructions should the nurse share? A. "Take this medication within 1 hour of waking each morning." B. "Limit your alcohol intake to 2 drinks per week while taking this medication." C. "It can take 6 weeks to achieve the full therapeutic effect of this medication." D. "Stop taking the medication if you experience dizziness."

"It can take 6 weeks to achieve the full therapeutic effect of this medication." *The nurse should instruct the client that it can take 6 to 8 weeks to achieve the full therapeutic effectiveness of a tricyclic antidepressant

A nurse is caring for a client who reports that the television set in the room is really a 2-way radio states, "Voices are coming from the TV, and everything we say in this room is being recorded." Which of the following responses should the nurse make? A. "What we say is not being recorded." B. "Let's ignore the voices and talk about something else." C. "That must be very frightening." D. "Why do you think the TV is a 2-way radio"

"That must be very frightening." *The nurse should respond to the client's delusion in a a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship

A nurse is preparing to administer lurasidone 80 mg PO daily to a client. Lurasidone is available as 40 mg tablets. How many tablets should the nurse administer?

2 tablets

A nurse on a mental health unit is caring for a group of clients. Which of the following is an example of a client using the defense mechanism of rationalization? A. A client who take opioids several times daily but refuses to admit she has a substance use disorder B. A client who bullies her partner because she is ridiculed at work C. A client who was physically abused as a child and cannot remember the events D. A client who states he drinks alcohol to excess because his marriage is failing

A client who states he drinks alcohol to excess because his marriage is failing *This is an example of the defense mechanism of rationalization

A nurse is collecting data from a client who has binge-eating disorder. Which of the following findings should the nurse expect? A. Amenorrhea B. Abdominal pain C. Restricted caloric intake D. Frequent use of laxatives

Abdominal pain *The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food

A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client? A. Tell the client that the nurse will talk to him at his request B. Allow the client to skip group activities if he chooses C. Leave the client alone for frequent rest periods throughout the day D. Build trust with the client by sitting quietly with him

Build trust with the client by sitting quietly with him *The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and using silence are actions that promote trust, which encourages the client to speak more openly about issues and concerns

A nurse is caring for a client who has anorexia nervosa. The client states, "If I gain weight, I'll never get a boyfriend." Which of the following cognitive distortions is the client displaying? A. Overgeneralization B. Personalization C. Emotional reasoning D. Catastrophizing

Catastrophizing *A client displays the cognitive distortion of catastrophizing by assuming the worst possible outcomes will occur

A nurse is caring for a client who has schizophrenia. The client states, "I like to play ball. Walk down the hall. Be careful; don't fall." The nurse should identify that the client is using which of the following patterns? A. Pressure speech B. Circumstantial speech C. Clang association D. Flight of ideas

Clang association *The nurse should recognize that this client is displaying clang association. Clang association is the stringing together of words because of their rhyming sounds, regardless of their meaning.

A nurse is planning care for a client who is experiencing complicated grief following the unexpected death of his partner. Which of the following actions should the nurse plan to take first? A. Positively reinforce new coping skills that increase the client's self-esteem B. Encourage the client to seek support from a counselor who specializes in grief C. Determine which stage of grief the client is experiencing D. Allow the client to express angry feelings associated with the grief

Determine which stage of grief the client is experiencing *The first action the nurse should take using the nursing process is to collect data to determine the stage of grief the client is fixed in to establish a baseline from which to plan care

A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of bipolar disorder. Which of the following behaviors should the nurse describe as a trigger for a relapse of mania? A. Using a daily planner B. Sleeping too much C. Eating too much protein D. Drinking alcohol

Drinking alcohol *The use of alcohol, caffeine, some over-the-counter medications, and some substances can trigger a relapse

A nurse is reviewing the laboratory report of a client who is taking risperidone. The nurse should identify that which of the following result indicates a potential adverse reaction to the medication? A. Elevated blood glucose B. Elevated WBC count C. Decreased platelet count D. Decreased aspartate transaminase (AST)

Elevated blood glucose *The nurse should identify that all second-generation antipsychotic medications such as risperidone can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. If there is no change after 12 weeks, glucose should be monitored annually

A nurse is collecting data from a client who has cocaine intoxication. Which of the following findings should the nurse expect? A. Low blood pressure B. Increased mental alertness C. Flat affect D. Decreased body temperature

Increased mental alertness *The nurse should expect a client who has cocaine intoxication to have increase mental alertness due to the substances stimulant properties

A nurse in a provider's office is assessing a client who is crying and states, "It's my child's first day of school." The nurse should recognize that the client is experiencing which of the following types of loss? A. Actual loss B. Maturational loss C. Perceived loss D. Situational loss

Maturational loss *A maturational loss is tied to a normal ,expected life change (e.g. children going to school or an adult moving out of state)

A nurse is assisting with the care of a client who is experiencing opioid withdrawal. Which of the following manifestation should the nurse expect? A. Hyporeflexia B. Muscle spasms C. Constipation D. Decreased respiratory rate

Muscle spasms *Muscle spasms are a manifestation of opioid withdrawal

A nurse is caring for a client who has bipolar disorder. Which of the following manifestations is the priority finding for the nurse to identify? A. Inability to concentrate B. Poor hygiene C. Hyperactivity D. Pressured speech

Hyperactivity *The greatest risk to this client is an injury from hyperactivity; therefore, the priority finding for the nurse to identify is hyperactivity. The nurse should intervene to redirect the client from unsafe activities. Constant activity can lead to exhaustion and even death

A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. For which of the following findings should the nurse question the provider's prescription? A. Skeletal muscle injury B. History of status epilepticus C. Hypotension D. Insomnia

Hypotension *The nurse should question the provider's prescription for a benzodiazepine. Benzodiazepine can cause severe hypotension and increase the client's risk for cardiac arrest

A nurse in a mental health facility is planning to promote the development of a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take? A. Begin each interaction by sharing a personal story B. Identify professional boundaries during the initial interaction C. Agree with the client's perceptions and emotions to encourage free expression D. Allow the client to meet with the nurse at any time during the day

Identify professional boundaries during the initial interaction *The nurse should promote a therapeutic nurse-client relationship by identifying distinct boundaries with the client. These boundaries help promote a therapeutic nurse-client relationship, rather than a social nurse-client relationship

A nurse is collecting data from a client who has been using a nicotine transdermal patch for smoking cessation. The client reports itching of the skin where the patch is applied. Which of the following statements should the nurse make? A. "You should change the location of the patch on your body." B. "Decreasing the strength of the patch should stop the itching." C. "You should discontinue using the patch." D. "This is an adverse effect of the patch that will subside in time."

"You should discontinue using the patch." *The nurse should instruct the client to discontinue the patch if persistent local reactions such as erythema, itching, or edema is experienced

A nurse is reinforcing teaching with a client who has a prescription for clozapine. Which of the following statements should the nurse include in the teaching? A. "You should have your white blood cell count checked once per week for 6 months." B. "You should check your weight every 3 days for weight loss." C. "You might experience frequent loose stools." D. "You might experience ringing in your ears."

"You should have your white blood cell count checked once per week for 6 months." *The nurse should instruct the client to complete laboratory testing of WBCs and neutrophils every week for 6 months

A newly admitted client who has major depressive disorder states to the nurse, "I'm a failure. I can't even cope with little things anymore." Which of the following responses should the nurse make? A. "What happened in your life to make you feel like such a failure?" B. "You sound like you're feeling pretty overwhelmed right now." C. "Do you feel like you don't deserve to be good to yourself?" D. "I know you feel like that now, but you'll feel differently when you get better."

"You sound like you're feeling pretty overwhelmed right now." *This response by the nurse acknowledges the client's feeling and attempts to convey the ability to understand them, which promotes a trusting relationship between the client and the nurse

A nurse is assisting with the admission of a client who has a hip fracture to the medical surgical care unit. The client states, "I've never been in the hospital before, and I'm feeling a lot of anxiety." Which of the following responses should the nurse make? A. "You're feeling anxious about being in the hospital for the first time." B. "Anxiety while in the hospital is a feeling many people experience." C. "Why do you think you feel anxious about being in the hospital?" D. "What activities do you enjoy when you are not in the hospital?"

"You're feeling anxious about being in the hospital for the first time." *The nurse should therapeutic communication when discussing the client's concerns. This statement is an example of restating, which encourages the client to continue talking and clarify any misunderstandings if necessary

A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan? A. Keep the door of the client's room to open while the client is awake B. Ensure that the client's meal tray contains no knives C. Observe the client swallow medications D. Have a staff member observe the client once every 30 minutes

Observe the client swallow medications *The nurse should plan to observe when the client swallows medications to ensure that he does not save the medications to take all at once

A nurse is assisting with a community presentation about Alzheimer's disease. The nurse should conclude that a member of the group requires further reinforcement of teaching when she identifies which of the following findings as a manifestation of Alzheimer's disease? A. Impaired judgment B. Sudden confusion C. Decreased attention span D. Short-term memory loss

Sudden confusion *The nurse should clarify that a client with Alzheimer's disease is expected to exhibit confusion that develops slowly over a period of months. Clients who have delirium exhibit sudden confusion

A nurse in a provider's office is reviewing the medical record of a client who has major depressive disorder and a new prescription for phenelzine. Which of the following items in the client's history should the nurse report to the provider? A. The client uses a transcutaneous electrical nerve stimulation (TENS) unit for back pain B. The client has frequent headaches C. The client takes glucosamine sulfate for arthritis D. The client has a history of tinnitus

The client has frequent headaches *Severe or recurrent headaches is a contraindication for taking phenelzine and other MAOIs. The nurse should report this finding to the provider

A nurse is collecting data from a client who has moderate cognitive decline due to stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? A. The client requires assistance with eating B. The client frequently gets lost due to wandering C. The client has bladder incontinence D. The client is able to identify the names of family members

The client is able to identify the names of family members *The nurse should expect a client who has stage 4 Alzheimer's disease to recognize and identify family members. Clients who have Alzheimer's disease maintain this ability until stage 6

A nurse is observing a client who has histrionic personality disorder. Which of the following behaviors should the nurse expect? A. The client whispers in the provider's ear B. The client refuses to provide her telephone number C. The client has diminished facial expressions D. The client asks if she is doing the right thing 3 times during the appointment

The client whispers in the provider's ear *Acting provocatively and seductively is an expected behavior of an individual with histrionic personality disorder

A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client? A. Therapeutic communication identifies and analyzes the client's problems B. Therapeutic communication builds a relationship that will allow expression of mutual concerns C. Therapeutic communication provides a foundation for the client's relationship with the provider D. Therapeutic communication ensures the client will remain cooperative with care in the facility

Therapeutic communication builds a relationship that will allow expression of mutual concerns *The purpose of therapeutic communication is to facilitate a relationship that will allow expression of mutual concerns in an effort to address the client's health issues

A nurse is caring for a client who is having an acute panic attack. Which of the following actions should the nurse take? A. Speak to the client in a raised voice B. Walk the client to the dayroom C. Use repetition when speaking with the client D. Secure the client in his room alone

Use repetition when speaking with the client *A client who is having a panic attack might have a hard time understanding what the nurse is saying. Using simple phrases and repetition are effective methods of communication

A nurse is caring for a client who has post-traumatic stress disorder (PTSD) and who is undergoing eye movement desensitization and reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies? A. Exposes the client to circumstances that trigger the PTSD B. Assists the client with behavioral modification C. Encourages the client to visualize a relaxing scene when traumatic memories occur D. Uses stimuli to change how the client processes the trauma

Uses stimuli to change how the client processes the trauma *EMDR uses stimuli such as tapping, eye movements, or audio sounds combined with verbalization of the traumatic event by the client. While the client recalls the traumatic event, these stimuli create neurological and physiological changes in how the client integrates the memories. EMDR is a type of psychotherapy carried out during several sessions by a therapist who is trained in the method

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse can safely administer which of the following medications while this client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

Valproic acid *Valproic acid and lithium are both indicated for the treatment of bipolar disorder. Therefore, the nurse can administer both of these medications to the client

A nurse is teaching a client who has schizophrenia about involuntary commitment. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "My family cannot commit me because I am homeless." B. "Even when I'm calm, I'll be forced to take psychotropic medication." C. "At least 2 doctors must support the commitment application." D. "At least 2 doctors must support the commitment application."

"At least 2 doctors must support the commitment application." *Involuntary commitment is a court-ordered mandate requiring admission of a client to receive mental health services either at an outpatient mental health facility. At least 2 doctors or other mental health professionals must agree that the client should be involuntarily committed to ensure due process and avoid accidentally committing the client

A nurse is reinforcing teaching with a client who has a new prescription for buspirone to treat anxiety. Which of the following statements should the nurse include in the teaching? A. "Use buspirone with caution because it raises the risk of suicidal thoughts." B. "You can minimize adverse effects by taking buspirone with grapefruit juice." C. "Buspirone enhances the depressant effects of alcohol." D. "Buspirone causes nausea in some people."

"Buspirone causes nausea in some people." *Adverse effects of buspirone include nausea, dizziness, headaches, nervousness, sedation, lightheadedness, and excitement

A nurse is participating with a disaster-support team following a tornado. When collecting data from a client who was affected by the tornado, which of the following questions should the nurse ask the client first? A. "Do you feel safe now that the tornado is gone?" B. "What do you think about the tornado?" C. "Do you have anyone you can contact for support?" D. "How do you usually cope with difficult situations?"

"Do you feel safe now that the tornado is gone?" *When using Maslow's hierarchy of needs, the nurse's priority is to determine if the client has a sense of safety

A nurse in a clinic is collecting data from a client who asks for help with depression. Which of the following questions is the nurse's priority? A. "Is there anything in particular that makes you feel angry?" B. "Have you had difficulty falling asleep or staying asleep?" C. "Have you thought about harming yourself in any way?" D. "Do you have someone you can talk with at home?"

"Have you thought about harming yourself in any way?" *The greatest risk to this client is an injury from self-harm; therefore, the nurse's priority is to determine whether the client is at risk by asking about thoughts of self-harm or a suicide plan

A nurse is collecting data from a client who has major depressive disorder. Which of the following questions is the priority for the nurse to ask the client? A. "Do you have any close friends?" B. "Can you describe how you feel about what's happening?" C. "Have you thought about hurting yourself?" D. "How are you dealing with being away from your family?"

"Have you thought about hurting yourself?" *The greatest risk to the client at this time is suicide. Therefore, the priority question the nurse should ask is if the client has any intent to self-harm

A nurse is reinforcing teaching with the partner of a client who has alcohol use disorder. Which of the following statements by the partner indicates an understanding of the teaching? A. "Having 6 beers in 2 hours is considered too much." B. "My partner is not at risk for cancer due to alcohol consumption." C. "My partner should consume no more than 20 drinks of alcohol in a week." D. "There is no genetic risk with abuse alcohol."

"Having 6 beers in 2 hours is considered too much." *Binge drinking refers to drinking too much alcohol in a short amount of time, causing the blood alcohol level to rise. This usually occurs with 5 or more drinks for males and 4 or more drinks for females within 2 hours

A nurse is reinforcing teaching with a client who has ADHD and a new prescription for a transdermal methylphenidate patch. Which of the following statements by the client indicates an understanding of the teaching? A. "I will rotate placing the patch on different parts of my upper body." B. "I can take showers with the patch in place." C. "If the patch bothers my skin, I will switch to the oral form of the medication." D. "I will apply a patch each night at bedtime."

"I can take showers with the patch in place." *The nurse should instruct the client that transdermal methylphenidate patches can be worn during bathing, showering, and swimming.

A nurse is collecting data from a client who has major depressive disorder regarding suicide risk factors and protective factors. Which of the following client statements should the nurse identify as a protective factor that decreases the client's risk for suicide? A. "I am a college graduate and make a lot of money at my profession." B. "I consider myself a good problem solver." C. "My family lives out-of-state, and I spend my spare time at home." D. "I enjoy restoring antique weapons and have a nice collection."

"I consider myself a good problem solver." *The ability to problem-solve and to think critically is a protective factor against suicide. Feelings of low self-esteem or hopelessness are risk factors for suicide.

A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation? A. "I don't want to live any longer." B. "I think every day about killing myself." C. "My parents will be happier when I'm dead." D. "I won't have to deal with things much longer."

"I won't have to deal with things much longer." *The nurse should listen closely for overt and covert statements that can indicate a client's intent to commit suicide. Covert statements can indicate in an indirect way a client's plan for suicide or wish to no longer be alive. Covert statements are more difficult to identify because they do not openly express the client's suicidal thoughts like overt statements. The nurse should collect further data from the client's suicidal ideation and implement interventions to reduce the risk of a suicide attempt

A nurse is caring for a client who has a depressive disorder. The client states, "I'm no good, spend your time with someone else." Which of the following responses should the nurse provide? A. "Why do you put yourself down?" B. "Did you go to group therapy yesterday?" C. "You will feel better soon if you follow your treatment plan." D. "I'm going to stay with you for a while if you would like to talk."

"I'm going to stay with you for a while if you would like to talk." *This response is therapeutic because it shows the client that the nurse is interested in her feelings, which strengthens the nurse-client relationship

A nurse is having a conversation with a newly admitted client when the client suddenly stops talking. Which of the following statements should the nurse make? A. "Apparently, you no longer wish to talk with me. Have I done something to make you angry?" B. "I've noticed you have become quiet. Share with me what you are thinking when you are ready." C. "It is okay if you don't wish to talk anymore right now. We can meet again tomorrow." D. "You need to talk during this time I have set aside for you. Talking is what will get you out of here."

"I've noticed you have become quiet. Share with me what you are thinking when you are ready." *This statement by the nurse is therapeutic. Focusing on the quietness sometimes helps the client talk about thoughts and feelings

A nurse is caring for a client who has schizophrenia and states, "My doctor is trying to kill me." Which of the following responses should the nurse make? A. "Why would you say that your doctor is trying to kill you?" B. "It must be frightening to feel that your doctor is trying to kill you." C. "You doctors wants to help you, not kill you." D. "How long has your doctor been trying to kill you."

"It must be frightening to feel that your doctor is trying to kill you." *When a client is experiencing a delusion, the nurse should empathize with the feelings behind the delusion.

A nurse is caring for a client who has major depressive disorder. The client states, "I might as well be dead. I have always been a failure." Which of the following responses should the nurse make? A. "Why do you think you feel this way?" B. "You have a great deal to offer in life." C. "Let's discuss these feelings further." D. "Feelings like a failure is expected with depression."

"Let's discuss these feelings further." *The nurse is using the therapeutic technique of exploring the client's feelings. The client's comments indicate a risk for self-harm, and the nurse should further explore to confirm this

A nurse is reinforcing teaching with the partner of a client who is at risk for alcohol withdrawal after 6 hours of cessation. Which of the following statements by the partner indicates an understanding of the teaching? A. "My partner might experience seizures after 3 days of abstinence." B. "Delirium tremens generally occurs within 24 hours." C. "Hypotension is a manifestation of alcohol withdrawal." D. "My partner might begin to shake."

"My partner might begin to shake." *Tremulousness is the classic sign of alcohol withdrawal, commonly called "the shakes" or jitters. Tremulousness begins 6 to 8 hours after alcohol cessation

A nurse is teaching with a client in the day room of an acute care mental health facility. The client accuses the nurse of being "too bossy" and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse provide? A. "What makes you say that?" B. "Tell me what I said that made you feel uncomfortable." C. "Why are you feeling pressured by me?" D. "You shouldn't make negative statements since I'm trying to help you."

"Tell me what I said that made you feel uncomfortable." *This statement uses the therapeutic technique of exploring to ask the client to explain her feelings. This can help the client view the situation objectively, enabling the nurse to determine the client's thoughts and promoting trust between the client and nurse

A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A. "A tornado is going to wipe us all out in 9 days." B. "My brain is dead, and my body is slowly rotting away." C. "The government is after me because I know top-secret information." D. "The TV is purposely playing commercials for things I don't like."

"The government is after me because I know top-secret information." *The nurse should identify this statement as an indication of a persecutory delusion

A nurse is caring for an adolescent male client who has anorexia nervosa. The client asks, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make? A. "What concerns do you have about your physical health?" B. "Let's wait to discuss that after you're feeling better." C. "Unconsciously, you're saying that you're worried about your physical appearance." D. "I'm glad you're concerned about the physical effects of your illness."

"What concerns do you have about your physical health?" *The nurse should use therapeutic communication when discussing the client's concerns. This statement by the nurse is an example of exploring, which encourages the client to talk further about personal feelings and perceptions

A nursing is preparing to administer alprazolam 4 mg PO divided equally every 12 hours for a client who has generalized anxiety disorder. The amount available is alprazolam 2 mg tab. How many tablets should the nurse administer per dose?

1 tablet

A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms? A. Compensation B. Repression C. Regression D. Suppression

Regression *Regression is reverting to a previous, more child-like behavior

A nurse is caring for a client who has anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms? A. Repression B. Splitting C. Conversion D. Projection

Repression *The nurse should identify that the client forgetting her partner's birthday following an argument is an example of repression. Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness

A nurse at an acute care facility is assisting with the care of a client who is receiving IV antibiotic treatments for an infection. The client reported daily alcohol use at home. On the seconds day of admission, the client becomes agitated, hypertensive, and tachycardic. Which of the following actions should the nurse plan to take? A. Administer methadone when agitation increases B. Administer zolpidem before meals C. Request a prescription for a different antibiotic D. Request a prescription for chlordiazepoxide

Request a prescription for chlordiazepoxide *The nurse should recognize these findings as indications of withdrawal from alcohol and should intervene to decrease adverse manifestations. Chlordiazepoxide, an anxiolytic, is a benzodiazepine prescribed for alcohol withdrawal that reduces manifestation and can help prevent seizures and delirium tremens

A nurse in the emergency room is collecting data from a client who has heroin intoxication. Which of the following findings should the nurse expect? A. Seizure activity B. Respiratory depression C. Hypersensitivity to pain D. Increased mental alertness

Respiratory depression *Heroin is an opioid; therefore, the nurse should expect this client who has heroin intoxication to exhibit respiratory depression.

A client states, "I haven't seen my child for 2 weeks." The nurse responds, "Your child has not visited you for 2 weeks?" Which of the following communication techniques is the nurse using? A. Accepting B. Making an observation C. Restating D. Voicing doubt

Restating *This is an example of the communication technique of restatement, which allows the nurse to verify what the client is saying and to provide an opportunity for the client to clarify any misunderstanding

A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of the following findings should the nurse expect? A. Restlessness B. Choking sensations C. Paresthesias D. Excessive sleepiness

Restlessness *Clients who have GAD are irritable and restless. They tend to worry excessively about circumstances others might consider minor

A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders? A. Paranoid B. Histrionic C. Antisocial D. Schizotypal

Schizotypal *Findings of schizotypal personality disorder include a pattern of social impairments and cognitive alterations, including superstitious actions that are not congruent with the client's cultural norms, speech changes (e.g. an increase in use of metaphors), and other elaborate speech patterns

A nurse is contributing to the plan of care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse recommend? A. Search the client and his belongings upon arrival B. Assign the client to a private room near the nurse's station C. Instruct assistive personnel to check on the client every 15 m in D. Keep the door to the client's room closed

Search the client and his belongings upon arrival *The nurse should plan to search the client and all of his belongings upon arrival to the unit. This search is conducted for the client's safety so that the nurse can identify and remove any objects that increase the client's risk of injury or suicide. Potentially harmfully objects include razors, shoelaces, hygiene products, and tweezers

A nurse is assisting with the admission of a client to an acute-care mental health facility following a suicide attempt. Which of the following actions should the nurse take first? A. Assess the client's level of self-esteem B. Document the client's mood and affect C. Attend an interdisciplinary team meeting D. Search the client's belongings

Search the client's belongings *The greatest risk to this client is self-injury from another suicide attempt; therefore, the nurse should first search the client's belongings to ensure there are no items that the client could use to harm herself.

A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The nurse should tell the client to expect which of the following adverse effects? A. Tinnitus B. Bradycardia C. Halitosis D. Sedation

Sedation *The client should expect sedation as an adverse effect of benzodiazepines because of the CNS depressant effects

A nurse is collecting dat from a school-aged child who has ADHD and has been taking desipramine. Which of the following adverse effects should the nurse expect the child's parent to report? A. Hyperactivity B. Depression C. Diarrhea D. Sedation

Sedation *The nurse should recognize that tryicyclic antidepressants can cause sedation, along with other anticholinergic effects. Therefore, the nurse should expect the parent to report that the child has been sedated

A nurse is reinforcing teaching with a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should reinforce with the client that TMS can cause which of the following adverse effects? A. Retrograde amnesia B. Seizures C. Confusion D. Suicidal ideation

Seizures *Although uncommon, seizures are a potential adverse effect of TMS

A nurse is caring for a client who has borderline personality disorder. Which of the following manifestations should the nurse expect? A. Self-mutilation B. Submission C. Exploitation of others D. Reclusive behavior

Self-mutilation *Clients who have borderline personality disorder exhibit impulsive behaviors such as suicidal plans and self-mutilation. Other impulsive behaviors include separation anxiety and splitting behaviors

A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the client's risk of which of the following adverse effects? A. Increased intracranial pressure B. Serotonin syndrome C. Acute kidney injury D. Hypertensive crisis

Serotonin syndrome *Serotonin syndrome is a toxic effect that can occur from taking an MAOI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability; these can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction

A nurse in a provider's office is collecting data from a client who has obsessive-compulsive disorder (OCD). Which of the following prescriptions should the nurse expect the client to receive? A. Donepezil B. Venlafaxine C. Buproprion D. Sertraline

Sertraline *Sertraline is a selective serotonin reuptake inhibitor (SSRI) medication which is prescribed for anxiety disorders, including OCD

A nurse is establishing a relationship with a client who has major depressive disorder (MDD) and is withdrawn and quiet. Which of the following actions should the nurse take? A. Leave the client alone in the room B. Silently observe the client's behavior C. Provide the client with false reassurance D. Use descriptive words when addressing the client

Silently observe the client's behavior *The nurse should observe the behavior of a client who has MDD and is withdrawn. The client might not be ready to share feelings with the nurse, and questioning the client can increase the client's anxiety level

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? A. Continue to talk if the client does not provide an immediate verbal response B. Use platitudes when talking with the client C. Ask the client direct questions D. Speak to the client using simple and concrete terminology

Speak to the client using simple and concrete terminology *The nurse should use simple and concrete terminology when communicating with this client. A client who is severely withdrawn has impaired comprehension and difficulty concentrating; therefore, this technique facilitates communication

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? A. Confront the client for breaking the rules B. Stand close to the client to offer comfort and support C. Speak to the client with clear, calm, caring statements D. Escort the client to the nurse's station

Speak to the client with clear, calm, caring statements *To remain in control of the situation, the nurse should use clear, calm statements that are nonthreatening to the client. The nurse should also set limits for clients who exhibit potentially violent behavior

A nurse is reinforcing teaching about ethics with a newly licensed nurse. Which of the following actions should the nurse include as an example of beneficence? A. Taking a continuing-education course about recognizing risk factors of suicide B. Spending extra time reorienting a client who is experiencing command hallucinations C. Acknowledging and accepting a client's refusal of a psychotropic medication D. Describing the purpose, action, and side effects of a psychotropic medication

Spending extra time reorienting a client who is experiencing command hallucinations *The nurse should include this action as an example of beneficence, which is the duty to act to promote the good of others. Reorienting a client who is experiencing command hallucinations is the best interest of the client and can protect the client from harm

A nurse is collecting data about the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills

Swallowing antidepressant pills *The nurse should assess the lethality of a client's suicide plan and identify whether it is a hard or soft method. Ingesting antidepressants or other pills is considered a soft method because it has a lower risk of resulting in death than hard methods. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun

A nurse is reinforcing dietary teaching with a client who has a new prescription for phenelzine, a monamine oxidase inhibitor (MAOI). The nurse should recognize that which of the following foods interacts with this medication? A. Swiss cheese B. Baked tilapia C. Banana D. Cottage cheese

Swiss cheese *Swiss cheese, and many other cheeses, are high in tyramine, which can interact with phenelzine. Phenelzine is an MAO that blocks neurotransmitters such as tyramine from being broken down. Therefore, ingestion of foods containing tyramine can increase the client's blood pressure and can cause a stroke. Foods that are high in tyramine should be avoided by a client who is taking an MAOI

A nurse is speaking with a client whose partner was killed unexpectedly. The client states, "I just don't know what to do now." Which of the following actions should the nurse take? A. Talk to the client about available community resources B. Distract the client by discussing events not related to the crisis C. Reassure the client that he will feel better soon D. Give the client advice about what to do during the next few days

Talk to the client about available community resources *Initial steps should be taken to make a client who is experiencing a crisis feel safe and less anxious. The priority for the nurse is to ensure the client is safe, which includes assessing any thoughts of self-harm. After promoting client safety, the nurse should let the client know what personal and community resources are available. The nurse should determine the client's perception of the crisis, availability of support, and ability to cope with the crisis.

A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take? A. Ask the client what she believes she did to deserve being physically abused B. Avoid documenting subjective verbatim statements from the client regarding injuries C. Talk to the client about making a safety plan D. Explain the cycle of violence to the client

Talk to the client about making a safety plan If the nurse concludes that physical abuse is occurring, it is important to support the client and take actions such as counseling the client about making a safety plan. The nurse should understand local laws regarding intimate partner violence and should report the incident as required

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? A. Talk to the client from 2-arm lengths away B. Obtain assistance to restrain the client for safety C. Firmly state to the client that morning care will be performed D. Call the provider to request a prescription for an antipsychotic medication

Talk to the client from 2-arm lengths away *The nurse should talk calmly and quietly to the client to decrease agitation. The nurse should remain 1 or 2 arm lengths away to provide a sense of personal space and maintain safety if she becomes aggressive

A nurse is contributing to the plan of care for a client who has a physical dependence on alprazolam and must discontinue the medication. Which of the following actions should the nurse recommend? A. Taper the medication gradually over several weeks B. Encourage participation in stimulating physical activity C. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication D. Implement restraints and seclusion as needed

Taper the medication gradually over several weeks *The nurse should recommend tapering the dosage of alprazolam gradually over several weeks, possible months. This gradual reduction in dosage reduces the manifestations of withdrawal

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol? A. Akathisia B. Acute dystonia C. Tardive dyskinesia D. Pseudoparkinsonism

Tardive dyskinesia *The nurse should identify that tardive dyskinesia can be manifested by involuntary movement of many body parts. Early findings include writhing movements of the tongue and smacking of the lips. The nurse should report these findings to the provider immediately because they might not be reversible and can progress to affect all extremities with rhythmic, uncontrollable writhing movements

A nurse is caring for a client who was voluntarily admitted to an inpatient mental health facility for treatment of major depressive disorder. After consenting to deep brain stimulation, the client tells the nurse he does not want to have the procedure. Which of the following actions should the nurse take? A. Explain that the provider is highly proficient in this therapy B. Tell the client that he has the right to refuse the procedure C. Explain that deep brain stimulation is a promising therapy for major depression D. Remind the client that agreeing to admission means the provider can proceed with the treatment

Tell the client that he has the right to refuse the procedure *Unless the client is a danger to himself or others, he has the right to refuse treatment, even after signing an informed consent form. The nurse should notify the provider to cancel the procedure

A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take? A. Insist that the parent tell the nurse how the child was injured B. Tell the parent that a child protective agency must be notified C. Show disapproval to the parent regarding the infant's condition D. Call at least 2 other staff members to sit in the room during the interview

Tell the parent that a child protective agency must be notified *The nurse should tell the parent that a state protective agency must be notified of the infant's condition and explain the process to the parent

A nurse is reinforcing teaching about stress management techniques with a parent who has admitted to verbally abusing her children. Which of the following strategies is the nurse providing? A. Tertiary prevention B. Individual psychotherapy C. Family psychotherapy D. Primary prevention

Tertiary prevention The nurse is providing tertiary prevention methods by offering stress management techniques to the abuser after the abuse has occurred. Tertiary prevention methods facilitate the rehabilitative process for both victims of violence and those who perpetuate it

A nurse is caring for a client who requests information about smoking cessation using nicotine gum. For which of the following reasons should the nurse recommend another over-the-counter smoking cessation product to the client? A. The client is overweight B. The client follows a vegan diet C. The client has dentures D. The client has insomnia

The client has dentures *The nurse should explain to the client that nicotine gum is difficult for clients who wear dentures to use and that using the gum can damage dental work. The nurse should recommend the nicotine patch or nicotine lozenges as an over-the counter alternative

A nurse is collecting data from a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache, and extreme thirst. The nurse should identify that which of the following situations is occurring? A. The client is experiencing mild acetaldehyde syndrome B. The client is having delirium tremens C. The client is experiencing disulfiram toxicity D. The client is not having a therapeutic response to disulfiram

The client is experiencing mild acetaldehyde syndrome *The nurse should recognize that these manifestations are an indication of acetaldehyde syndrome, which occurs when alcohol consumption is combined with disulfiram use. The client's current manifestations represent the mild form of acetaldehyde symptoms that can occur by consuming as little as 7 mL (0.2 oz) of alcohol

A nurse in a provider's office is collecting data on a client who is taking paroxetine for the treatment of social anxiety. Which of the following information from the client should the nurse reports to the provider immediately? A. The client reports a change in appetite B. The client is experiencing insomnia C. The client reports being depressed D. The client is experiencing headaches

The client reports being depressed *A report of depression indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding

A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the pas 2 months. Which of the following findings demonstrates that the chlorpromazine has been effective? A. The client reports that hallucinations occur less frequently B. The client sleeps uninterrupted for 6 hours each night C. The client reports that she is the "most important person on the unit." D. The client demonstrates stereotyped behaviors

The client reports that hallucinations occur less frequently *The nurse should identify that a primary action of chlorpromazine, when used to treat schizophrenia, is to reduce hallucinations. Chlorpromazine, a first-generation conventional antipsychotic medication, is effective in decreasing delusions, hallucinations, and agitation. It can also treat manic behavior in clients who have bipolar disorder

A nurse in a provider's office is reviewing the results of a mental status exam for a client who has early manifestations of dementia. Which of the following pieces of information from the examination describes the client's cognitive status? A. The client has a flight of ideas B. The client shows a deficit in recent memory C. The client has a flat affect D. The client is well groomed

The client shows a deficit in recent memory *This report about the client's memory describes the client's cognitive status. Other areas include orientation, level of consciousness, attention, and judgment

A nurse is collecting data from a client who has bipolar disease. Which of the following actions is an indication the client is experiencing a manic stage? A. The client speaks rapidly with a sense of urgency B. The client touches everything within her reach C. The client states that she is unable to enjoy her favorite activities D. The client moves slowly and maintains a fixed gaze

The client speaks rapidly with a sense of urgency *The nurse should recognize that a client who is experiencing a manic episode often talks with pressured speech. This form of speech is rapid, frenetic, and often coherent and has a false sense of urgency

A nurse is caring for a client who is taking carbamazepine. The nurse should monitor the client for which of the following adverse effects of carbamazepine? A. Thrombocytopenia B. Weight loss C. Polyuria D. Insomnia

Thrombocytopenia *The nurse should monitor the client for thrombocytopenia (an increased risk of bleeding). The nurse should monitor for bleeding of the gums, which can indicate thrombocytopenia, and notify the provider if this occurs.

A nurse is collecting data on a client who antisocial personality disorder. Which of the following manifestations should the nurse expect in the client's personality? A. Unconcerned about obeying the law B. Suspicious of others C. Unsociable with peers D. Requires excessive admiration

Unconcerned about obeying the law *A client who has antisocial personality disorder is deceitful and manipulative and lacks empathy for others. Clients who have antisocial personality disorder are risk takers, show a lack of responsibility for their actions, and frequently disobeys the law

A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for this client? A. Walking with a staff member B. Playing ping-pong in the dayroom with another client C. Playing basketball with other clients in the gym D. Riding on a stationary bike alone in the fitness room

Walking with a staff member *The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff

A nurse is caring for a client who has delirium. Which of the following items should the nurse use to promote optimal cognitive function for this client? A. Identification bracelet B. Menu for the cafeteria C. Map of the facility D. Wall calendar

Wall calendar *A wall calendar can offer a client who is experiencing delirium environmental cues for reorientation and memory

A nurse is collecting data from a client who has panic disorder and has been taking paroxetine. Which of the following assessments should the nurse identify as an adverse effect of the medication? A. Peripheral edema B. Chest congestion C. Shuffling gait D. Weight gain

Weight gain * Weight gain is an expected adverse effect of paroxetine and other SSRIs. Other adverse effects include nausea, headaches, insomnia, and sexual dysfunction

A nurse is caring for a client who has been taking lithium for the past several months. Which of the following findings should the indicate that the client is experiencing advanced lithium toxicity? A. Increased thirst B. ataxia C. Diarrhea D. Fine hand tremors

ataxia *The nurse should identify that ataxia, which is the lack of coordination of body movements, is a manifestation of advanced lithium toxicity. Other manifestations can include seizures, blurred vision, severe hypotension, large output of dilute urine, and clonic movements as signs of advanced lithium toxicity. The nurse should notify the provider immediately if these symptoms occur

A nurse is assisting with a support group for clients who are nearing discharge from an acute care mental health facility. During a group session, a client states, "I'm scared about being discharged." Which of the following responses should the nurse offer? A. "Maybe you are not ready to be discharged yet." B. "Are there others in the group who have similar feelings they would like to share?" C. "You ought to be happy that you're being discharged." D. "How many in the group feel this member is not yet ready to be discharged?"

"Are there others in the group who have similar feelings they would like to share?" *Some of the goals of a support group include providing improved interpersonal relationships, mutual support, and methods to decrease stress. By asking if others in the group have similar feelings, the nurse allows the client to hear that feelings regarding discharge are not unique; also, the client might receive support from group members who express similar feelings

A client who has cognitive impairment tells the nurse, "I'm leaving now. I have to be home by 5:00 PM because dinner will be ready." Which of the following responses by the nurse demonstrates the use of validation therapy? A. "It it 5:30 PM now. You are in the hospital and we will bring you dinner soon." B. "Don't worry about dinner. Your father is bringing dinner here for you tonight." C. "At home, you had dinner at 5:00 PM. Was your father a good cook?" D. "Your father was born around the year 1920. Can you tell me what year it is now?"

"At home, you had dinner at 5:00 PM. Was your father a good cook?" *This response validates the client's feelings and redirects the conversation to another topic so that the client can talk about personal memories. Validation therapy does not attempt to orient the client to reality but instead recognizes the underlying feelings expressed by the client and then redirects the conversation

A nurse is reinforcing teaching with a client who has anxiety and a new prescription for buspirone. Which of the following pieces of information should the nurse include in the teaching? A. "Buspirone carries a high potential for abuse." B. "Avoid consuming grapefruit juice when taking this medication." C. "Take the medication 4 times daily." D. "The peak effects of buspirone occur within 1 week."

"Avoid consuming grapefruit juice when taking this medication." *The nurse should instruct the client to avoid drinking grapefruit juice when taking buspirone because it can cause levels of the medication to increase. Elevated levels can cause drowsiness and subjective effects such as dysphoria

A nurse is reinforcing teaching with a client about cannabis use disorder. Which of the following client statements indicates an understanding of the teaching? A. "Withdrawal of cannabis occurs 3 days after cessation." B. "There are no physical manifestation of withdrawal from cannabis." C. "Drug screens can detect cannabis for up to 8 weeks after use." D. "Cannabis use can produce effects resembling the effects of alcohol use."

"Cannabis use can produce effects resembling the effects of alcohol use." *The nurse should explain to the client that, when used moderately, cannabis produces effects resembling the effects of alcohol and other CNS depressants. By depressing higher brain centers, CNS depressants release lower centers from inhibitory influences

A nurse in a mental health clinic is working with a client whose partner recently started working overseas. The client states, "My youngest child is having difficulty coping with my partner's absence." Which of the following responses should the nurse offer? A. "You should administer punishment if your child acts out." B. "Continue to do the activities that your family did before your partner's absence." C. "You child should see a counselor if he doesn't adjust to your partner's absence within 2 weeks." D. "Give your child the opportunity to spend as much time alone as he needs"

"Continue to do the activities that your family did before your partner's absence." *The nurse should instruct the client to continue usually family activities from before the partner's absence and to encourage the child to resume his usual activities. Returning to familiar activities can help re-establish a sense of normalcy for the family

A nurse on a rehabilitation unit is reinforcing teaching with the partner of a client who is experiencing stimulant withdrawal. Which of the following statements by the partner indicates an understanding of the teaching? A. "Increased energy is a sign of withdrawal." B. "Depression is a manifestation of withdrawal." C. "Decreased appetite is a manifestation of withdrawal." D. "Delirium tremens can occur during withdrawal."

"Depression is a manifestation of withdrawal." *The nurse should explain to the partner that depression and suicidal thoughts are the most serious adverse effects of stimulant withdrawal

A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask? A. "How would you describe your mood?" B. "How are you sleeping?" C. "Do you drink alcohol or use other substances?" D. "Do you ever think about suicide?"

"Do you ever think about suicide?" *The diagnosis of major depressive disorder indicates that the greatest risk for this client is suicide. Therefore, the priority for the nurse to ask is about suicidal ideation. Research shows that clients who have depressive disorders are at high risk for suicide due to the common presence of recurring thoughts of death

A nurse is reinforcing teaching with the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include? A. "Donepezil can improve cognitive functioning during the earlier stages of the disease." B. "Donepezil cures the disease process if it is started upon first recognition of dementia." C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease." D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."

"Donepezil can improve cognitive functioning during the earlier stages of the disease." *The nurse should inform the client's family that donepezil is used to treat the manifestations of mild to severe Alzheimer's disease. Although donepezil does not prevent the progression of Alzheimer's disease, it is intended to prolong the client's ability to function in the early stages of the disease

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for lorazepam. Which of the following statements should the nurse include? A. "Taking an antacid with the medication will decrease stomach upset." B. "Expect the medication to cause insomnia for the first 1 to 2 weeks." C. "Drinking caffeinated beverages will decrease the effectiveness of the medication." D. "Increase the dosage if the effectiveness of the medication decreases."

"Drinking caffeinated beverages will decrease the effectiveness of the medication." *The nurse should inform the client that consuming caffeine while taking benzodiazepines such as lorazepam will result in decreased effectiveness of the medication. Caffeine is a stimulant, and lorazepam is a CNS depressant; therefore, the substances will counteract each other. The client should avoid consumption of caffeine while taking this medication

A nurse is reinforcing teaching with a client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make? A. "Feelings of sedation should resolve in about 1 week." B. "There is no risk of physical dependence with this medication." C. "You can decrease the dose when you feel especially anxious." D. "It will take several months for you to feel the maximum benefit maximum benefit of the medication."

"Feelings of sedation should resolve in about 1 week." *Adverse effects of diazepam and other benzodiazepines are sedation and psychomotor slowing. The nurse should inform the client that these effects should subside in 7 to 10 days."

A nurse is reinforcing teaching with a family member of a client who has newly diagnosed with nyctophobia. Which of the following statements by the family member shows an understanding of the teaching? A. "He becomes anxious during electrical storms." B. "He avoids parties because he is afraid of meeting strangers." C. "He quit his job because he was afraid of entering the storage room." D. "He is unable to sleep without a light on."

"He is unable to sleep without a light on." *Clients who have nyctophobia are afraid of the dark. This phobia occurs often in children but can also occur in adults

A nurse is talking with an adolescent client who has major depressive disorder. The client tells the nurse into a situation in which he feels a friend betrayed him. Which of the following responses should the nurse offer? A. "Why should you feel betrayed by this friend?" B. "You'll get over this friend in time." C. "How does this situation make you feel?" D. "Jealousy will not help your friendship."

"How does this situation make you feel?" *This response by the nurse explores the client's feelings and encourages the expression of further ideas by the client

A nurse is caring for a client who has social anxiety disorder. Which of the following client statements should the nurse expect? A. "I am embarrassed to eat in public." B. "I often feel like I am going to have a heart attack." C. "I struggle to control my constant worry." D. "I have to step over the cracks in the sidewalk or else something bad might happen."

"I am embarrassed to eat in public." *The nurse should recognize that this statement describes social disorder. Clients who have this disorder experience severe anxiety or fear of behaving in a manner that can be negatively viewed by others. These clients attempt to avoid activities such as eating or speaking in public. If they are unable to avoid activities that trigger the anxiety, clients experience severe anxiety and emotional distress

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms? A. "I just feel so hopeless." B. "The government has been watching my house." C. "I am unable to remember to brush my teeth." D. "I no longer enjoy the activities I used to love."

"I am unable to remember to brush my teeth." *The nurse should recognize that memory impairment is a cognitive symptom of schizophrenia. Other cognitive symptoms include impaired concentration, judgment, and problem-solving

A nurse is reinforcing with the guardian of a school-aged child who has ADHD and a new prescription for clonidine. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will not allow my child to eat anything within 2 hours of taking the medication." B. "I can expect my child to be drowsy while taking this medication." C. "I will give my child a dose of the medication at noon every day." D. "I will cut the tablet in half before giving it to my child."

"I can expect my child to be drowsy while taking this medication." *The nurse should instruct the guardian that clonidine can cause adverse effects like somnolence, fatigue, and hypotension

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? A. "Her mannerologies are poor." B. "My dog blank a boa to supreme heights." C. "I can play the flute while wearing a suit. You are cute." D. "My joints ache. My friend is in the joint."

"I can play the flute while wearing a suit. You are cute." *The nurse should recognize that this statement is an example of clang association. Clang association refers to the use of words that are based on sound rather than meaning. A client who has schizophrenia will often use words that rhyme or have a similar beginning sound

A nurse is collecting data from a client who has adjustment disorder. Which of the following statements by the client should the nurse recognize as a manifestation of this disorder? A. "I am unable to remember my address." B. "I feel like I am living in a fog." C. "I sometimes cannot remember large blocks of time." D. "I could have done something to prevent my cousin's death."

"I could have done something to prevent my cousin's death." *The nurse should recognize that this statement indicates adjustment disorder, which occurs as a response to a stressful event. Manifestations can include guilt, depression, anxiety, and anger. These feelings might accompany physical manifestation, social withdrawal, or work or academic changes. The disorder can be treated with antidepressant medications

A nurse is interacting with a client who has a psychotic disorder when the client suddenly turns her head as if listening to something and says, "The boss says she is going to hit me with a stick!" Which of the following responses should the nurse offer? A. "The boss can't hurt you with that stick B. "Why are you talking to yourself?" C. "I don't see anyone, but it sounds like you are frightened." D. "There isn't anyone here but you and me, so you need to explain."

"I don't see anyone, but it sounds like you are frightened." *The nurse should respond by offering personal perceptions of the client's experience and should address the client's underlying emotions about the hallucination

A nurse in a mental health clinic is collecting data from a client who recently lost her partner after an extended illness. Which of the following statements by the client indicates that she might be experiencing major depressive disorder as opposed to typical grief? A. "I still sometimes get angry over this happening to my partner." B. "I feel no pleasure without my partner in my life." C. "I see reminders of my partner every day." D. "I feel like I should have done more to take care of my partner."

"I feel no pleasure without my partner in my life." *The inability to experience pleasure (anhedonia) is a manifestation of depressive disorder. In a typical grief reaction, the survivor may be sad and have feelings of emptiness but is still able to experience moments of pleasure

A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse recognize as an erotomaniac delusion? A. "My coworker is trying to poison me because he is afraid I'll take his job." B. "I have only met Jenny twice, but I know she'll love me." C. "I am selling my house before the earthquake hits in May." D. "The foil on my walls prevents the government from controlling me."

"I have only met Jenny twice, but I know she'll love me." *The nurse should recognize that a client who believes another person desires him or her romantically after meeting only a few times is demonstrating an erotomaniac delusion

A nurse is interacting with a client in a substance use disorder program. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission? A. "I was just using the medication to help me out during a rough time in my life. I can stop whenever I want." B. "This all happened because my spouse is unemployed. That puts an enormous amount of stress on me." C. "I have read that problems with substances can have a variety of predisposing factors." D. "I just don't want to talk about it. Anyway, there is nothing you can do to help."

"I have read that problems with substances can have a variety of predisposing factors." *The nurse should identify this response as intellectualization, which is an attempt to use intellectual processes to avoid expressing the emotions that stem from stressful situations

A nurse is talking with a client who has anxiety disorder. The client states, "I have something important to tell you, but you have to promise to keep it a secret." Which of the following responses should the nurse make? A. "Anything you tell me is kept private between us." B. "I feel uncomfortable being asked to keep a secret for you." C. "Why do you feel that the information needs to be kept private?" D. "I might have to share the information with your provider."

"I might have to share the information with your provider." *The nurse should be honest with the client so that the client can decide whether to share the information. The information the client shares can be vital for the treatment plan and can present a safety risk for the client or others. Therefore, the nurse might be legally obligated to share the information with the client's provider and health care team

A nurse is reinforcing teaching with a client who has a new prescription for buspirone. Which of the following statements by the client indicates an understanding of the teaching A. "I need to watch for signs of dehydration." B. "I need to have my kidney function monitored while taking this medication." C. "I should take this medication on an empty stomach." D. "I might not notice the effects of this medication for several weeks."

"I might not notice the effects of this medication for several weeks." *The effects of buspirone develop slowly. The initial response takes at least a week, and a peak response takes several weeks. Because of the delayed action, buspirone should not be taken as a PRN medication for the relief of anxiety

A nurse is collecting data from a group of clients who have paraphilic disorders. Which of the following client statements should then nurse identify as an indication that a client has necrophilia? A. "I was arrested for making obscene phone calls." B. "I enjoy taking nitrous oxide prior to have an orgasm." C. "I like my partner to urinate on me during sex." D. "I often fantasize about having intercourse with a corpse."

"I often fantasize about having intercourse with a corpse." *A client who has a paraphilic disorder obtains sexual arousal or orgasm from stimuli or acts that are outside of societal norms. Fantasizing about having sex with a corpse is an expected behavior for a client who has an "other specified" paraphilic disorder of necrophilia. The presence of a paraphilic disorder does not necessarily mean the client will act on the thought or ideas

A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence? A. "Last night my partner beat me worse than ever before." B. "It'll be easier just to make my partner mad and get the violence over with." C. "I believe my partner is remorseful and won't hurt me again." D. "I only got shoved a little bit, and it was my fault for coming home late."

"I only got shoved a little bit, and it was my fault for coming home late." *This statement is an indicator of the tension-building phase of the cycle of violence. During this phase, episodes of violence are often minor, and the recipient might rationalize the episodes by accepting blame

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect? A. "I pick my face when I am nervous." B. "I have bald patches from pulling out my hair." C. "I inspect my body in the mirror several times a day." D. "I am unable to part with any of my belongings."

"I pick my face when I am nervous." *The nurse should recognize that this statement is an indication of excoriation disorder. Clients who have excoriation disorder typically pick their faces when experiencing stress or anxiety

A nurse is providing discharge teaching to the parent of an adolescent client who has bulimia nervosa and has been hospitalized for several weeks. Which of the following statements should the nurse identify as an indication that the parent understands the teaching? A. "I should allow my child to make independent decisions." B. "I should give my child a laxative every evening." C. "I should make sure my child takes an antipsychotic medication several times daily." D. "I should discourage my child from exercising."

"I should allow my child to make independent decisions." *Clients who have bulimia nervosa often demonstrate low self-esteem. The family should support the client emotionally and should encourage increasing independent decision making

A nurse is leading a group therapy session for a group of clients. Which of the following client statements should indicate to the nurse that the client is using the defense mechanism of rationalization? A. "I became a team manager because I'm not tall enough to succeed at basketball." B. "I don't want to talk right now about the fire that destroyed my home." C. "I take amphetamines because it's the only way I can keep up with all the studying for my classes." D. "I will spend a day cleaning my house when I feel like my life is out of control."

"I take amphetamines because it's the only way I can keep up with all the studying for my classes." *Rationalization is the act of justifying unacceptable thoughts or behaviors with a seemingly acceptable explanation. Rationalization allows the client to protect the ego and avoid taking responsibility for actions or thoughts that can cause shame of embarrassment

A nurse in an acute care mental health facility is assisting with the evaluation of the plan of care for a client who has major depressive disorder and was admitted 1 week ago following a suicide attempt. Which of the following client statements should indicate to the nurse that the treatment plan has been effective? A. "I just don't want to talk about anything that has happened before my admission." B. "I was feeling completely hopeless when I tried to kill myself." C. "I am feeling really great today, and I think I am ready to go home." D. "I want to punch the doctors who put me in this hospital."

"I was feeling completely hopeless when I tried to kill myself." *This statement should indicate to the nurse that the client is meeting a short-term goal of being willing to discuss painful feelings that occurred at the time of the suicide attempt. The nurse should also evaluate whether the client is now willing to see help when feelings o self-harm occur

A nurse is reinforcing teaching with a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching? A. "If I fail to stop smoking after 12 weeks, I will have to try another product." B. "I will take them medication for 7 days before I try to stop smoking." C. "This medication will cause me to lose weight as I stop smoking." D. "I will take the medication after eating a meal."

"I will take the medication after eating a meal." *The nurse should instruct the client that taking varenicline following a meal with a full glass of water will minimize the associated nausea

A nurse is reinforcing teaching with the parents of a school-aged child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? A. "Ignore your child's attention-seeking behaviors that are not dangerous." B. "Administer ADHD medications within 30 min of your child's bedtime." C. "Continue with an activity as planned even if your child becomes frustrated." D. "Expect your child to gain weight after starting ADHD medications."

"Ignore your child's attention-seeking behaviors that are not dangerous." *The nurse should instruct the parents about the use of planned ignoring. This technique ignores attention-seeking behaviors that are not dangerous to the child or others. If the child learns that the behavior will not elicit the desired response, then the behavior should decrease

A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he isn't going to attend any further sessions and states, "I don't have time for all that talking." Which of the following responses should the nurse provide? A. "It must be difficult for you to talk about family problems." B. "You should continue attending the family counseling sessions until the therapist tells you to stop." C. "If you continue to go to family counseling, I'm sure you'll be able to resolve your family problems soon." D. "I think you need to continue family therapy if your partner and children want to receive further counseling."

"It must be difficult for you to talk about family problems." *The nurse's response indicates empathy for the client's feelings and is an example of the therapeutic communication technique of verbalizing what the client implied. With this technique, the nurse helps him focus on the actual reason for not wanting to continue family therapy

A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique of reflection? A. "It sounds like you are concerned about your family's reaction." B. "What your family thinks isn't important; you need to be concerned about getting well." C. "I suspect your family doesn't seem to understand you. D. "Many clients are concerned about the reaction of their families."

"It sounds like you are concerned about your family's reaction." *In a reflective response, the nurse directs feelings and statements back to the client, allowing the client to think about personal feelings

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A. "Can you tell my why you do not want to participate in the planned group activity?" B. "Do you understand that psychotropic medications cause weight gain?" C. "The aerobics class will be more effective at burning calories than walking." D. "It sounds like you have come up with an alternative exercise that works for you."

"It sounds like you have come up with an alternative exercise that works for you." *The nurse is using therapeutic techniques of acceptance, giving recognition, and encouragement by supporting the client's idea of a way to exercise

A nurse at a long term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions? A. "We will be serving breakfast in 10 min. I will stay here while you get ready." B. "It's Monday morning. I know that your favorite television shows are on this evening." C. "I see that you have a new photo on the wall. Can you tell me who that girl is?" D. "It's almost time for your appointment. Let me do your hair for you and brush your teeth."

"It's almost time for your appointment. Let me do your hair for you and brush your teeth." *When a client with dementia has periods of confusion, the AP should allow the client additional time to complete activities that can be performed independently. Insisting on completing the task for the client or attempting to hurry her can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or needs it

A nurse is caring for a client who has antisocial personality disorder. The client uses manipulation to gain access to a smoking area from which his access has been limited as a behavioral intervention. Which of the following statements should the nurse make? A. "You know you shouldn't use the smoking area." B. "You know that manipulation is not the right thing to do." C. "Let's review the consequences of your actions." D. "I can talk with the provider about reducing your smoking restriction."

"Let's review the consequences of your actions." *When communicating with a client who has antisocial personality disorder, the nurse should set clear and realistic limits on behavior that all staff members adhere to, identify the client's undesirable behavior, and communicate the consequences of that behavior

A nurse in an acute mental health facility is caring for a client who states, "This place is ridiculous. I can't stand spending another day here!" Which of the following responses should the nurse make? A. "You should focus on the good things so the bad things seem less important." B. "I'm sure tomorrow will be a better day." C. "You shouldn't be so negative when you are young and physically healthy." D. "Let's talk for a while about the events of your day."

"Let's talk for a while about the events of your day." *The nurse should use focusing as a therapeutic communication technique that encourages the client to talk about feelings.

A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make? A. "Light therapy suppresses the natural nighttime release of melatonin." B. "You should plan your light therapy session before going to bed." C. "You should begin with 2-minute light therapy sessions and gradually progress to 10-minute sessions." D. "Light therapy is less effective at treating SAD than antidepressant medications."

"Light therapy suppresses the natural nighttime release of melatonin." *Melatonin is produced nocturnally by the pineal gland; larger amounts are produced during months containing more hours of darkness. These large amounts of melatonin seem to cause SAD in clients who are susceptible to this disorder. Light therapy is thought to improve depression by suppressing melatonin production and increasing serotonin production

A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement? A. "I smoked for years, but now I cannot stand to be around cigarette smoke." B. "I didn't get the promotion at work because my boss hates me." C. "My partner yelled at me, so I made the cat go outdoors." D. "I won't worry about losing my job until my child's break from school is over."

"My partner yelled at me, so I made the cat go outdoors." *This statement is consistent with the use of displacement. Displacement is the transference of emotions associated with a person, object, or situation to another non-threatening person, object, or situation.

A nurse in a long-term mental health facility is caring for a client who has a personality disorder. Because the client has broken a unit rule, phone privileges are being revoked. The client asks the nurse, "Can't I just make another phone call?" Which of the following responses should the nurse make? A. "No, you can't. Go sit in your room." B. "Okay, if you promise to obey the rules for the rest of the day." C. "No, you can't. You have broken the rules that apply to everyone." D. "You can make only a 5-minute phone call."

"No, you can't. You have broken the rules that apply to everyone." *The nurse's response correctly enforces unit rules, identifies the reason for the consequence, and decreases the likelihood of future manipulative behavior

A nurse on an acute care mental health unit is collecting data from a client who was admitted following an opioid overdose. The client states that he wants his admission to remain confidential. Which of the following responses should the nurse make? A. "There is no way we can keep the details of your admission a secret from other people." B. "Being admitted as a confidential client will cost extra." C. "Only the staff involved in your care will know the details of your admission." D. "We will only release information about your admission to your family members."

"Only the staff involved in your care will know the details of your admission." *Keeping the details of a client's admission and care confidential is a legal requirement as as part of the nurse's ethical duty. The nurse should inform the client that only members of the staff who are involved in his care will have access to information about his admission and treatment

A nurse is caring for a client who has Alzheimer's disease. The client's adult son reports that the client has begun wandering away from home. Which of the following responses should the nurse make? A. "You should plan to move your mother into your home soon." B. "Place a complex lock at the top of each door that leads outside." C. "It is time to place your mother in a long-term care facility." D. "Have you reminded your mother about the dangers of wandering away from home?"

"Place a complex lock at the top of each door that leads outside." *The nurse should instruct the client's son to place complex locks at the top of doors that lead outside to prevent the client from wandering away from home. The nurse should also encourage the client's son to place a non-removable medical alert bracelet on the client with the client's name, address, and telephone number

A nurse is assisting a client who has major depressive disorder. The client states, "This has been the worst day of my life." Which of the following responses should the nurse make? A. "You should focus on positive things rather than negative things." B. "We all have a bad day from time to time." C. "Why would someone with so much to live for say that?" D. "Please take a seat and talk to me about it."

"Please take a seat and talk to me about it." *This response by the nurse is therapeutic and encourages the client to talk about his feelings and what might have caused them. This helps the nurse develop a trusting relationship with the client, in which the client will feel safe opening up to the nurse. Using therapeutic communication techniques helps to identify the client's specific needs and problems, which can lead to a solution

A nurse is caring for a client who is confused and wanders at night. The nurse asks the charge nurse if the client can be placed in physical restraints at bedtime. Which of the following responses should the charge nurse provide? A. "Restraints can be used if the client is having verbal outbursts." B. "Restraints have been effective in reducing the number of client falls." C. "Restraints can used only when the unit manager approves." D. "Restraining the client can increase confusion."

"Restraining the client can increase confusion." *Restraining a confused client can worsen confusion. The nurse should use other methods to prevent wandering such as suggesting diversional activities, reducing stimulation, and administering a PRN medication

A nurse is reinforcing teaching with the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will not set time limits for discussing her delusions." B. "We will avoid reacting to her command hallucinations." C. "She might lose weight due to her medications." D. "She might be having a relapse if she stops attending social events."

"She might be having a relapse if she stops attending social events." *The family of a client who has schizophrenia should be taught the signs of relapse, including avoiding other people, sleep disturbances, difficulty concentrating, and being unable to tell reality from nonreality

A nurse is caring for a client who has bipolar disorder. The client states, "My family wants me to come home for a visit. What do you think I should do?" Which of the following responses should the nurse make? A. "Tell me how you are feeling about their request." B. "I think spending some time with your family is important." C. "Maybe you shouldn't go if you're not sure about the visit." D. "What does your social worker think you should do?"

"Tell me how you are feeling about their request." *This statement is an example of a therapeutic response because the nurse is inquiring how the client feels and using reflection to encourage independent thinking

A nurse is caring for a client who is dying. The client's son appears visibly upset when he visits. Which of the following statements should the nurse make to the client's son? A. "Tell me how you're feeling about your mother's illness." B. "Consider bringing a support person when you visit your mother." C. "It is okay to feel angry when losing someone close to you." D. "You should think about joining a grief support group."

"Tell me how you're feeling about your mother's illness." *The nurse is using a therapeutic communication technique of offering a general lead to allow the son to express his feelings. This statement indicates that the nurse is interested in not only the client but also the client's family

A nurse in a rehabilitation center for clients with substance use disorders is collecting data from a client who is being admitted. The client tells the nurse, "I am afraid of other people finding out that I am in a rehabilitation center." Which of the following responses should the nurse make? A. "You don't need to worry about that." B. "You should be proud of yourself for getting treatment." C. "Why do you care what other people think?" D. "Tell me more about how you are feeling about being here."

"Tell me more about how you are feeling about being here." *The nurse is using therapeutic communication by exploring the client's feelings and encouraging the client to discuss them.

A nurse is caring for a client who is postoperative following an amputation of the left lower leg. The client states, "I can't believe this happened to me. I don't deserve this." Which of the following responses should the nurse make? A. "Tell me what you're feeling about what has happened?" B. "The feelings you're having are normal following an amputation." C. "I agree with you. You did not deserve this." D. "What makes you say that you don't deserve this?"

"Tell me what you're feeling about what has happened?" *The nurse should use therapeutic communication when discussing the client's concerns. This statement is an example of exploring, which encourages the client to talk further about personal feelings and perceptions

A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make? A. "Aliens do not exist." B. "Has your daughter had her baby?" C. "Do you mean to say a laboratory technician drew your blood last night?" D. "That does not sound real."

"That does not sound real." *The nurse is voicing doubt with this response, which expresses uncertainty regarding the reality of the client's conclusion of the hallucination. This is a therapeutic response because the statement allows the client to expand upon the earlier statement, which allows exploration of the client's thought processes

A nurse on a mental health unit is receiving reports about a group of clients. Which of the following client statements is an example of a persecutory delusion? A. "I am the mayor of this town." B. "My doctor is in love with me." C. "That other nurse is trying to poison me." D. "The end of the world is coming tonight."

"That other nurse is trying to poison me." *This statement is an example of a persecutory delusion in which the client believes that someone is trying to cause harm

A mental health nurse is reviewing a process recording of a therapy session with a client. Which of the following statements should the nurse identify as an example of the communication technique of reflection? A. "I notice you are pulling on your hair when we discuss your dismissal." B. "That statement made by the other client appears to have upset you." C. "Since writing in your journal is frustrating, we should look at this activity more closely." D. "Give me an example of a time when you felt no one understood you."

"That statement made by the other client appears to have upset you." *Reflective statements are useful in assisting a client with identifying emotions and ideas. This therapeutic communication technique validates the client's emotions and encourages the client to reflect more deeply on the emotion

A nurse in a health clinic is reinforcing teaching with a client about binge eating disorder. Which of the following client statements indicates an understanding of the teaching? A. "This problem is caused by a slow metabolism." B. "The abdominal pain I often have is due to the amount of food that I eat." C. "Most of my weight gain is water weight." D. "At least I do not need to worry about being physically ill."

"The abdominal pain I often have is due to the amount of food that I eat." *Gastrointestinal complications can arise for clients who have binge eating disorder due to the larger than normal amount of food they consume. Other manifestations include constipation, diarrhea, urgency, and a feeling of anal blockage

A nurse is reinforcing teaching with a client who reports depression and has a new prescription for an SSRI medication. Which of the following statements should the nurse make? A. "You should avoid foods with tyramine while taking this medication." B. "If the adverse effects are too bothersome, stop taking the medication." C. "Drinking alcohol is allowed with this type of medication." D. "The effect of the medication may take several weeks to be felt."

"The effect of the medication may take several weeks to be felt." *The nurse should reinforce with the client that the therapeutic effect of SSRIs may take 1 to 4 weeks to be felt. If no effect is felt by 4 weeks, the client should notify the provider, and a change in dosage or medication may be prescribed. The client should continue to take the medication as directed, even if symptoms improve. A relapse of depression can occur if the medication is stopped

A nurse is reinforcing teaching with a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make? A. "You will get very sick if you drink alcohol while taking this medicaion. B. "The medication will be administered as a subcutaneous injection." C. "You should take this medication on an empty stomach." D. "The medication might cause you to have episodes of diarrhea."

"The medication might cause you to have episodes of diarrhea." *The nurse should instruct the client that an adverse effect of acamprosate is diarrhea

A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching? A. "You can take this medication when needed." B. "The medication takes a few weeks to build up in your system." C. "You should plan to take this medication for 6 months." D. "Relapsing after withdrawing from this medication is rare."

"The medication takes a few weeks to build up in your system." *The nurse should inform the client that initial effects of paroxetine take about 4 weeks to develop. Optimal effects of the medication can be seen in 8 to 12 weeks

A nurse is reinforcing teaching with the partner of a client who has conversion disorder. Which of the following statements by the partner shows an understanding of the teaching? A. "My partner is pretending to be ill to get attention." B. "My partner is purposely making our child sick." C. "The stress of losing our child caused my partner to go blind." D. "My partner is worried that he has cancer, even though his tests are normal."

"The stress of losing our child caused my partner to go blind." *The nurse should explain to the partner that conversion disorder manifests as deficits in motor or sensory functions. Emotional conflict or stress is reflected in physical manifestations that can include paralysis, blindness, movement disorder, numbness, paresthesia, loss of hearing, or episodes resembling epilepsy

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for venlafaxine. Which of the following statements should the nurse make? A. "This medication is only for short-term use" B. "This medication can be taken on an as-needed basis." C. "This medication will effectively reduce your physical manifestations of anxiety." D. "This medication should not be stopped abruptly."

"This medication should not be stopped abruptly." *The nurse should instruct the client that stopping venlafaxine abruptly will lead to manifestations of withdrawal.

A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, "Can I vote in the upcoming presidential election?" Which of the following responses should the nurse make? A. "Why do you want to vote while you are in the hospital?" B. "I wouldn't worry about voting right now." C. "We can work together to find out how you can get a mail-in ballot." D. "You'll have a lot more opportunities to vote after you get better."

"We can work together to find out how you can get a mail-in ballot." *The nurse provides a therapeutic response by suggesting collaboration and formulating a plan of action that will result in giving the client information and addressing the client's need

A nurse on a mental health unit is caring for a client who asks the nurse out to dinner. Which of the following responses should the nurse provide? A. "You should ask one of the other client if they'd like to go to dinner with you." B. "Why are you asking me out to dinner?" C. "We have a professional relationship, not a personal relationship." D. "We should discuss this some other time."

"We have a professional relationship, not a personal relationship." *This statement is therapeutic because it clarifies the purpose of the relationship between the nurse and the client

A nurse is caring for a client who returns to the unit from day pass 2 h ours late. The client has slurred speech, and the nurse smells alcohol on the client's breath. What should the nurse say to the client in response to this situation? A. "Why are you returning late from your day pass?" B. "How much did you drink? You know drinking is against the rules." C. "We will need to discuss your actions after you've had a chance to sleep." D. "I'm disappointed that you were not more responsible while on a day pass."

"We will need to discuss your actions after you've had a chance to sleep." *This response is therapeutic because the client is unable to process this behavior while under the influence of alcohol

A nurse is reinforcing teaching about decreasing codependent behaviors with the family of a client who has alcohol use disorder. Which of the following statements by a family member indicates an understanding of the teaching? A. "We will help her financially if she loses her job." B. "We will not hold her responsible for her alcohol use." C. "We will routinely search for and remove any alcohol in her home." D. "We will not let our moods be changed by her behavior."

"We will not let our moods be changed by her behavior." *The nurse should explain to the family that alcohol use is self-inflicted and that the client must take responsibility for her actions. The family should not allow the client's dysfunctional behavior to control their environment. Establishing boundaries with the client is the family's first step in reducing the codependent behaviors

A nurse is reinforcing teaching with the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by a family member indicates an understanding of ECT? A. "We are so glad there are no physical side effects of shock treatment." B. "Thank goodness there is no permanent memory loss." C. "Cardiac dysrhythmias can persist for several weeks." D. "We won't be alarmed if there is some confusion after the treatment."

"We won't be alarmed if there is some confusion after the treatment." *It is common following ECT for a client to experience confusion and disorientation

A nurse is reinforcing teaching with the parent of a child who has a new prescription for methylphenidate to treat ADHD. Which of the following instructions should the nurse include in the teaching? A. "Weigh your child 3 times per week." B. "Expect your child to experience dark-colored stools." C. "Administer this medication at bedtime." D. "You should limit your child's intake of caffeine."

"Weigh your child 3 times per week." *The nurse should instruct the parent to weigh the child 2 to 3 times per week. Weight loss is an adverse effect of this medication. If significant weight loss occurs, the parent should notify the provider.

A nurse is collecting data from a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A. "I thought I hear something too." B. "Is someone telling you something?" C. "What are you hearing?" D. "There is nobody in that chair for you to listen to."

"What are you hearing?" *This open-ended question allows the nurse to find out what the client is hearing without validating the hallucination as real. The nurse should watch the client for anxiety or fear and ensure that the hallucination is not commanding the client to hurt self or others. After an assessment of the client's hallucinations is complete, the nurse can develop a plan to decrease the hallucinations.

A nurse is caring for a client who is receiving cognitive-behavioral therapy. The client tells the nurse, "Nothing good ever happened during my marriage." When using cognitive reframing, which of the following responses should the nurse provide? A. "Let's discuss what you considered to be negative about your marriage." B. "What activities do you enjoy that take your mind off your marriage experience?" C. "What did you learn from your marriage to help you in the future?" D. "Only you can understand how your marriage negatively affected your life."

"What did you learn from your marriage to help you in the future?" *Cognitive-behavioral therapy, specifically cognitive reframing, asks the client to restructure thoughts to try to learn from situations perceived as negative. The intended purpose is to help the client identify misconceptions and work toward developing more accurate and positive perceptions. This response encourages the client to look at the situation more positively to find the benefits of experience

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client informs the nurse, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? A. "That is silly. You look just fine to me." B. "Nobody expects you to look good in a hospital." C. "I understand. Would you like to wash your hair?" D. "Would you like to talk about why you feel this way?"

"Would you like to talk about why you feel this way?" *This response by the nurse acknowledges the client's feelings and conveys the ability to understand them, which promotes a trusting relationship between the client and the nurse

A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? A. "Yesterday, my partner put on a jacket upside down." B. "My partner has trouble reading the newspaper." C. "My partner often repeats words." D. "Last week, my partner did not recognize the sound of the alarm clock."

"Yesterday, my partner put on a jacket upside down." *The nurse should recognize that this statement is an indication that the client is experiencing apraxia (the lack of ability to accomplish once known tasks). This manifestation is considered a cognitive deficit because there is no loss of motor or sensory ability.

A nurse is caring for a client who has schizophrenia and has been admitted to the mental health unit. The client has a history of aggression and has been continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make? A. "It's a beautiful day outside. Let's take a walk together." B. "Sit down so we can try a relaxation exercise." C. "Would you like your antianxiety medication now?" D. "You are pacing back and forth. Can you tell me what you are feeling?"

"You are pacing back and forth. Can you tell me what you are feeling?" *The first action the nurse should take using the nursing process is to collect data from the client. By asking the client to identify feelings of anxiety, the nurse promotes trust and can assist the client with decreasing anxiety before an episode of aggression occurs

A nurse is reinforcing teaching with a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include? A. "If you're trying a benzodiazepine medication, you should take it before the procedure." B. "You can expect to wake up about 15 minutes after the procedure." C. "After the first procedure, you should expect to have ECT sessions monthly for a year." D. "ECT is the primary treatment for most clients who have depression."

"You can expect to wake up about 15 minutes after the procedure." *A client who undergoes ECT usually wakes up about 15 minutes after the procedure and can be disoriented for several hours after.

A nurse on a psychiatric unit is talking with a client who makes a sexual advance toward the nurse. Which of the following responses should the nurse provide? A. "It's normal for you to have sexual feelings toward the staff." B. "You need to stop any type of sexual advances." C. "This behavior is unacceptable while I am your nurse." D. "What would your family think of this type of behavior?"

"You need to stop any type of sexual advances." *The nurse should clearly identify behavior expectations to help promote and maintain appropriate boundaries

A nurse is reinforcing teaching with a client who is scheduled for electroconvulsive therapy (ECT) to treat major depression. Which of the following pieces of information should the nurse include? A. "You will be awake during the procedure." B. "You will experience a seizure during this procedure." C. "You can't eat or drink anything for 24 hours before the procedure." D. "You are not required to sign an informed consent form for this procedure."

"You will experience a seizure during this procedure." *The nurse should inform the client that the procedure will involve a seizure. ECT induces a generalized seizure of the brain by electrical current. ECT increases neurotransmitters in the brain, which can assist with treating the client's depression

A nurse is reinforcing teaching with a client who has agoraphobia about systemic desensitization. Which of the following comments should the nurse include in the teaching? A. "You will watch from a secure location as your therapist goes to public spaces." B. "You will start your therapy by staying in a public space until your anxiety decreases." C. "You will be instructed to say "Stop!" out loud when you become anxious in public spaces." D. "You will slowly be exposed to increasing levels of public spaces."

"You will slowly be exposed to increasing levels of public spaces." *The nurse should inform the client that, using systemic desensitization, she will be gradually exposed to the feared situation under controlled conditions until she learns to overcome the anxious response

A nurse is caring for a client who left the facility without permission and has had outside privileges revoked for 1 week. The client asks the nurse if she can take a short walk outside the facility. Which of the following responses should the nurse provide? A. "Your privileges have been revoked. I'd be glad to help you find something to do inside the unit." B. "I think it would be good for you to take a walk, but your doctor has take away your privileges." C. "You decided to leave the hospital without permission. Why are you asking to go outside today?" D. "We shouldn't discuss this. Let's talk about what you want to do when you are discharged."

"Your privileges have been revoked. I'd be glad to help you find something to do inside the unit." *This response demonstrates the technique of offering self to the client. It reinforces the reality of the client's current situation, offers the client another option for a permitted activity, and conveys the nurse's willingness to spend quality time with the client

A nurse is collecting data for a client who has anorexia nervosa. Which of the following findings should the nurse expect? A. Hyperthermia B. Alopecia C. Hypertension D. Warm skin

Alopecia *The nurse should expect a client who has anorexia nervosa to have alopecia, which is a finding consistent with malnourishment and dehydration. The client may also have lanugo (fine, downy hair growth) on the face and back

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? A. Apply mechanical restraints to the client B. Administer PRN haloperidol IM to the client C. Approach the client in a nonthreatening manner D. Place the client in seclusion

Approach the client in a nonthreatening manner *The first action the nurse should take is to approach the client calmly to create a nonthreatening environment.

A nurse is collecting data from a client who has post-traumatic stress disorder (PTSD) due to a sexual assault that occurred 3 months ago. Which of the following findings should the nurse expect? A. Increased hours of sleep each day B. Repeatedly talking about the assault C. Dreaming about the assault D. Decreased responsiveness to stimuli

Dreaming about the assault *The nurse should expect the client who has PTSD to report recurring dreams about the assault

A nurse is planning care for a client who has dissociative disorder and is experiencing flashbacks while in public. Which of the following interventions should the nurse include in the plan to help the client recognize and counter the flashbacks? A. Encourage reality testing B. Provide opportunities for socialization C. Consistently remind the client of past traumatic events D. Discourage client expressions of negative feelings

Encourage reality testing *Reality testing involves scanning the surrounding to see if others are afraid and reorientations to time and place. This can help clients recognize that the flashbacks are not real

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of playing staff members against each other. Which of the following actions should the nurse take? A. Have the same staff members work with the client on a long-term basis B. Listen to the client when he reports feelings about other staff members C. Explore the client's use of clinging and distancing behaviors with him D. Arrange for the client to share complaints with the nursing supervisor

Explore the client's use of clinging and distancing behaviors with him *Splitting is a common defense mechanism demonstrated by clients who have BPD in which the client plays staff members against each other. First, the client expresses feelings of attachment toward a certain staff member and then abruptly begins issuing complaints about this person to other staff members. The underlying cause of splitting is a fear of abandonment and an inability to accept both positive and negative feelings. Therefore, the client demonstrates only negative or positive feelings toward others

A nurse is preparing to meet with a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship? A. Introduce the concept of client confidentiality B. Establish goals with the client C. Define the roles of the nurse and the client D. Facilitate change in the client's behavior

Facilitate change in the client's behavior *The nurse should facilitate change in the client's behavior during the working phase of the therapeutic relationship.

A nurse is collecting data from a client who has oppositional defiant disorder. Which of the following findings should the nurse expect? A. Flat affect B. Unmotivated by rewards C. Ignoring unit rules D. Fearing a loss of privileges

Ignoring unit rules *The nurse should expect a client who has oppositional defiant disorder to ignore and break rules or requests from those in positions of authority

A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for lithium. Which of the following directions should the nurse provide? A. Decrease sodium intake while taking lithium B. It may take 5 days before the medication is effective C. Take the medication on an empty stomach D. Increase the fluid intake to 2000 mL (67.6 oz) daily

Increase the fluid intake to 2000 mL (67.6 oz) daily *The client should consume 1500 to 3000 mL (50.7 to 101.4 oz) of fluid daily

A nurse is collecting data from a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate the administration of lorazepam? A. Decreased pulse rate B. Increased blood pressure C. Decreased urinary output D. Increased nausea

Increased blood pressure *Lorazepam is a benzodiazepine that is administered to a client who is experiencing alcohol withdrawal for stabilizing vital signs, preventing seizures, and treating delirium tremens. The nurse should anticipate the provider to prescribe lorazepam for increasing blood pressure

A nurse is reinforcing teaching with a client who has a new prescription for bupropion. The nurse should instruct the client to report which of the following findings as an adverse effect of bupropion? A. Hypotension B. Blurred vision C. Tinnitus D. Insomnia

Insomnia *The nurse should instruct the client to report insomnia, which is an adverse effect of bupropion. Other adverse effects can include anxiety, delusions, hypertension, dry mouth, nausea, weight loss or gain, and photosensitivity

A home health nurse is reinforcing teaching for the family who has moderate Alzheimer's disease. The family plans to care for the client in their home. Which of the following recommendations should the nurse include in the teaching? A. Place nonskid throw rugs over smooth surface floors B. Install locks at the top of exterior doors C. Provide clothing that has zippers instead of buttons D. Encourage frequent naps during the day

Install locks at the top of exterior doors *This client is at an increased risk of wandering and getting lost. A safety intervention to decrease the risk of wandering is to install locks at the tops of exterior doors since a client who has moderate Alzheimer's disease loses the ability to reach and look upward

A nurse is assisting with planning an in-service session about involuntarily commitment to mental health facilities for a group of newly licensed nurses. Which of the following pieces of information should the nurse recommend including? A. The client can challenge hospitalization following emergency treatment B. Involuntarily commitment requires the hospitalization of the client C. A client who is competent but committed involuntarily is unable to make treatment decisions D. Court hearings should be held 7 days after emergency commitment

Involuntarily commitment requires the hospitalization of the client *A client can be court-ordered to undergo outpatient psychiatric treatment as well as inpatient treatment. Involuntary outpatient treatment is used most often for clients who have severe and chronic mental illness in order to limit the need for inpatient admissions for the client

A nurse is collecting data on a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? A. Demonstrates extroverted behavior to gain attention B. Is always on guard around other people C. Is rigid about following rules and procedures D. Has an exaggerated sense of self-importance

Is always on guard around other people *A client who has paranoid personality disorder is hypervigilant and is always on guard because of a perception that others are out to get them. Clients who have this disorder are often tense and irritable and avoid interacting with other people

A nurse is determining the total score for a client's Alcohol Use Disorders Identification Test (AUDIT) by assigning a score of 0 to 4 for each of the client's answers. For which of the following self-reported findings should the nurse assign the client a score of 4? A. The client's frequency of alcohol intake is typically 3 times per week B. The client misses work once a month because of his alcohol intake C. Alcohol intake does not cause the client to have feelings of guilt D. Last month, the provider suggested that the client reduce his alcohol intake

Last month, the provider suggested that the client reduce his alcohol intake *When determining a client's total score for the AUDIT self-reported version, the nurse should assign a score of 4 if the client indicates that a friend, relative, or health care provider recommended decreasing his alcohol consumption at least once during the last 12 months

A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. The nurse should explain that the provider will routinely prescribe which of the following tests while the client is taking valproic acid? A. Electrocardiogram B. Chest X-ray C. Thyroid function tests D. Liver function levels

Liver function levels *The nurse should inform the client of the need to monitor liver function levels regularly due to the risk of hepatotoxicity while taking valproic acid. It is is recommended to obtain baseline levels and then repeat testing every 2 months during the first 6 months of therapy.

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A. Assign the client several tasks at the same time B. Maintain a low-stimulation environment C. Advise family to visit frequently as a group D. Encourage the client to make choices regarding care

Maintain a low-stimulation environment *To minimize confusion and anxiety, the nurse should maintain a low-stimulation environment who has demenita

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? A. Maintain the client's contact with her family B. Discourage the client's use of vulgar language C. Protect the client from impulsive behavior D. Redirect excessive energy to creative tasks

Protect the client from impulsive behavior *The nurse should protect this client who is manic from impulsive behavior that increases the client's risk of self-harm

A nurse is caring for a client who has dementia and paces during meals. Which of the following actions should the nurse take? A. Restrain the client during meals B. Offer a large meal to the client at bedtime C. Administer an antipsychotic medication D. Provide finger foods for the client

Provide finger foods for the client *The nurse should provide finger foods to encourage intake throughout the day and improve the client's nutritional status

A nurse is contributing to the plan of care for a client who has binge-eating disorder. Which of the following interventions should the nurse recommend? A. Weigh the client each day B. Provide the client with small, frequent meals C. Observe the client during meals for hiding food D. Offer liquid supplements during meals

Provide the client with small, frequent meals *The nurse should recommend providing small, frequent meals to the client. Long periods without food can cause a client who has a binge-eating disorder to relapse and overeat

A nurse in a community mental health facility is caring for a group of clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis? A. A client who has a new diagnosis of severe bipolar disorder B. A client who is depressed following a devastating fire in her home C. A client who is experiencing acute grief following his father's death D. A client who is experiencing postpartum depression following the birth of her first child

A client who is depressed following a devastating fire in her home *The nurse should identify that a client who is experiencing depression following a house fire is experiencing an adventitious crisis. An adventitious crisis is unplanned and not a part of everyday life. The crisis can result from a natural disaster, a national disaster, or a crime of violence

A nurse is caring for 4 clients in a community mental health facility. For which of the following clients should the nurse provide a tertiary care intervention? A. A client who has generalized anxiety disorder and reports increased anxiety and insomnia B. A client who is expressing hopelessness during a crisis C. A client who is recovering from a crisis and asks for help in completing the recovery process D. A client who is having difficulty coping with stress and wants to learn relaxation techniques

A client who is recovering from a crisis and asks for help in completing the recovery process *This client should receive tertiary care interventions such as a referral to community groups or facilities to complete recovery from a crisis. Tertiary care is designed to provide support for mental and physical healing after a crisis occurs

A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client? A. CAGE Assessment B. Hamilton Anxiety Rating Scale C. Abnormal Involuntary Movement Scale (AIMS) D. SAFE-T Tool

Abnormal Involuntary Movement Scale (AIMS) *The AIMS is an assessment tool that identifies and tracks involuntary movements in clients who have tardive dyskinesia

A nurse is caring for a client who has an alcohol use disorder and is currently undergoing alcohol detoxification. Which of the following interventions should the nurse provide at this time? A. Administer substitution therapy medications B. Teach the client the physical symptoms of withdrawal C. Provide the client with information about a 12 step program D. Identify the causes of the client's alcohol use disorder

Administer substitution therapy medications *During alcohol detoxification, the nurse should provide substitution therapy prescribed by the provider to ease the symptoms of withdrawal

A nurse in a mental health clinic is collecting data from an older adult client who is tearful and reports sleep disturbances. The client tells the nurse, "All of my friends have died, and my children are too busy for me." Which of the following actions should the nurse take first? A. Contact the client's family for support B. Administer the Geriatric Depression Scale C. Refer the client to his provider for an antidepressant medication D. Encourage the client to join a senior support group

Administer the Geriatric Depression Scale *The first action the nurse should take using the nursing process is to assess the client by administering the Geriatric Depression Scale to determine if he is clinically depressed and, if so, assess the severity of the depression. This assessment will allow the nurse to understand the particular needs of the client

A nurse is collecting data from a client who was recently admitted for treatment of major depressive disorder (MDD). Which of the following findings should the nurse expect the client to report? (Select all that apply) A. Difficulty sleeping for several weeks B. Inability to concentrate on simple tasks C. Desire for sexual activity with multiple partners D. Not bathing for several days E. Lack of enjoyment from a long-time hobby of gardening

1. Difficulty sleeping for several weeks 2. Inability to concentrate on simple tasks 3. Not bathing for several days 4. Lack of enjoyment from a long-time hobby of gardening *The nurse should expect a client who has MDD to report either difficulty sleeping or excessive, indecisiveness and an inability to concentrate, a lack of personal hygiene and self-care, and anhedonia, which is the inability to feel pleasure or happiness from a hobby or activity that once provided these positive feelings

A nurse is reinforcing discharge teaching with the guardians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as an indication of acute mania? (select all that apply) A. Complete school projects B. Naps during the daytime C. Eats large amounts D. Spends excessive amounts of money E. Speaks using a loud and crass voice

1. Spends excessive amounts of money 2. Speaks using a loud and crass voice *A client who has acute mania is impulsive and at risk of spending excessive amounts of money despite financial status. Additionally, a client who has acute mania has rapid speech and quick thoughts; other alterations in speech include speech that is vulgar or sexually explicit

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of the medication every 72 hours C. Offer the client a PRN aspirin while taking the medication D. Administer the medication at bedtime

Administer the medication at bedtime *Donepezil is used to treat the manifestations of mild to moderate Alzheimer's disease. The nurse should administer this medication at bedtime to reduce the risk of injury due to bradycardia

A nurse is collecting data from clients who are prescribed medications that can cause orthostatic hypotension. Which of the following medications requires a follow-up by the nurse? A. Phenelzine B. Escitalopram oxalate C. Galantamine D. Naltrexone

Phenelzine *Phenelzine is a monoamine oxidase inhibitor that is prescribed for depression and other mental health disorders. An adverse effect of phenelzine is orthostatic hypotension. The nurse should inform the client who is taking phenelzine that dizziness an lightheadedness are indications of hypotension. The nurse should also instruct the client to rise slowly from a side-lying or sitting position to minimize a drop in blood pressre

A nurse in a long-term care facility is caring for a client who has dementia and becomes increasingly agitated in the afternoon hours. Which of the following actions should the nurse take first? A. Place the client in a private room B. Apply soft wrist restraints to the client C. Administer haloperidol to the client D. Offer diversionary activities for the client

Offer diversionary activities for the client *When providing client care, the nurse should use the least restrictive intervention first; therefore, the nurse should offer activities to distract the client and redirect agitation and energy into behaviors that might calm the client

A nurse is reinforcing teaching with the caregiver of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Offer the client a list of activities to choose from B. Offer finger foods to the client C. Discourage naps throughout the day D. Turn on the television when the client is in the room

Offer finger foods to the client *The caregiver should offer finger foods that the client can eat without sitting down. Clients who have dementia often like to wander and walk off nervous energy, which can decrease anxiety and calm the client.

A nurse is contributing to the plan of care for a group of clients. Which of the following interventions is the priority for the nurse to include? A. Offer high-calorie beverages to a client who is in the manic phase of bipolar disorder B. Practice relaxation techniques with a client who has anxiety disorder C. Assist a client who has depressive disorder with decision-making regarding group activities D. Reinforcing teaching to a client who has schizophrenia about a new prescription for clozapine

Offer high-calorie beverages to a client who is in the manic phase of bipolar disorder *Maslow's hierarchy of needs; therefore, the priority intervention is to offer the client high-calorie beverages. This intervention will help the client meet daily calorie requirements and prevent dehydration

A nurse is assisting with the planning of a staff education session about the administration of antidepressant medications to older adult clients. Which of the following pieces of information should the nurse recommend including? A. Older adult clients require a lower initial dose of antidepressant medication than adult clients B. Older adult client should not receive antidepressant medication C. Older adult clients achieve the therapeutic effects of antidepressant medications more quickly than adult clients D. Older adult clients have a decreased risk of adverse effects from antidepressant medication

Older adult clients require a lower initial dose of antidepressant medication than adult clients *Older adult clients should start at half of the adult dose for antidepressant medications. This is due to altered rates of absorption and the increased risk of adverse effects

A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances? A. Amphetamines B. Opiates C. Barbiturates D. Hallucinogenics

Opiates *The administration of methadone is indicated for the treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of opiate withdrawal

A nurse is planning to work with a client to develop a set of goals. During which of the following phases of the therapeutic relationship should the nurse complete this task? A. Pre-orientation phase B. Orientation phase C. Working phase D. Termination phase

Orientation phase *The orientation phase is the period during which the nurse and the client become acquainted, establish rapport and boundaries, and develop goals and a plan of action to meet these goals. During this phase, the nurse also explains the nurse's role in maintaining confidentiality

A nurse is caring for a client who is taking olanzapine. For which of the following adverse effects should the nurse monitor? A. Orthostatic hypotension B. Tinnitus C. Hypoglycemia D. Tachycardia

Orthostatic hypotension *The nurse should monitor the client for orthostatic hypotension as an adverse effect of olanzapine. Other adverse effects of this medication can include bradycardia, agitation, dizziness, sedation, headaches, cough, dyspnea, abdominal pain, and photosensitivity

A nurse is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD) following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe? A. Bupropion B. Phenelzine C. Mirtazapine D. Paroxetine

Paroxetine *The nurse should expect the provider to prescribe paroxetine, an SSRI that is considered the first-line treatment for PTSD.