ATI RN Mental Health

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?

Anhedonia

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make everyday decisions.

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?

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

A charge nurse is preparing an education session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?

"In the event a client threatens harm to others, medications can be administered without consent."

A nurse is teaching the parent of a 10 year old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching?

"Administer the last dose of medication to your child 6 hours before bedtime." An adverse effect of dextroamphetamine is insomnia. Therefore, the nurse should instruct the parent to administer the last dose of medication to the child 6 hr before bedtime. The parent can expect the child to experience CONSTIPATION, first dose should be given after breakfast and weight loss.

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?

"I am able to go to work every day, so I don't have a problem."

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client that the client is using denial as a defense mechanism?

"I am able to go to work every day, so I don't have a problem." By insisting that his drinking is not a problem because he can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of his substance use disorder.

A nurse is assisting a client who has a terminal illness adjust to progressively loss of independence. Which of the following statements by the client indicates acceptance or her illness?

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

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning." When a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief.

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning." - The nurse should identify that when a client has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief.

A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication?

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

A nurse is providing teaching to the partner of a client who is in rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?

"I will not take charge of my partner's work responsibilities." It is important for the individual who has the substance use disorder to take charge of personal responsibilities.

A nurse is teaching coping strategies to a client who is experiencing depression related to intimate partner abuse. Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?

"If you do my homework for me, I won't bother you for the rest of the day."

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?

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

A nurse is teaching the parents of a client about their daughter's diagnosis of bulimia nervosa. Which of the following statements made by the parents indicates an understanding of their daughter's illness?

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

A nurse is caring for client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

"It is not uncommon to feel angry toward yourself or others."

A nurse is caring for a client who child has terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

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

A nurse is caring for an older adult client who begins to cry and states, " I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?

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

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse?

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

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make?

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

A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching?

"Take this medication with food." Lithium can cause gastrointestinal distress. Therefore, this medication should be taken with food.

A nurse in the emergency department is admitting a client who reports a headache along with heart palpitations after having a glass of wine with dinner a few hours ago. The client has history of depression and has blood pressure of 210/105 mm Hg. Which of the following questions should the nurse ask first?

"What medications are you currently taking?" The nurse should verify what medication the client is currently taking, including MAOI medication to treat depression. The client's history of depression indicates that this client is at the greatest risk for hypertensive crisis from MAOI medications used to treat depression. These medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine.

A nurse is teaching a client who has depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

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

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

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

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/ml. How many mL should the nurse administer? Round to nearest 10th.

1.5 7.5/5

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weights 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

14 mL

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?

A client who has borderline personality disorder threatened to harm their roommate.

A nurse is planning care for four clients in mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs?

A client who has severe Alzheimer's disease The greatest risk to this client is injury from performing ADLs. Clients who have severe Alzheimer's disease are typically confused, have memory difficulties, tend to wander, and need assistance to perform ADLs.

A nurse in an acute mental health facility is receiving change of shift report for four clients. Which of the following clients should the nurse assess first?

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

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?

Permit the client to perform daily rituals to decrease anxiety. Allowing clients who have delirium to practice daily rituals will decrease frustration and anxiety.

A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?

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

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

A client was administered one-half of the prescribed dose of medication.

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for flings indicating lithium toxicity?

A client who has a sodium level of 128 mEq/L

A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? Select all that apply.

A client who is suicidal and in need of rapid treatment is correct. ECT can be used when there is a need for a rapid, definitive response for a client who is suicidal. A client who has recently been diagnosed with severe depression is incorrect. ECT is not an appropriate first-line treatment for a client with a recent diagnosis of depression. A client who has bipolar disorder with rapid cycling is correct. ECT works best for a client who has bipolar disorder with rapid cycling. A client who has mania and has not responded to medication therapy is correct. ECT is indicated for clients who have mania and have not responded to medication therapy. A client whose depression is secondary to situational difficulties is incorrect. ECT is not effective for clients whose depression stems from situational or social problems.

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

A client who is taking lamotrigine and has developed a rash

A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse?

A family where one or both parents witnessed intimate partner violence in the home as children Parents who witnessed intimate partner violence as children are more likely to become abusive themselves. Therefore, this is the family group with the greatest potential for future child abuse.

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?

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

A nurse is reviewing the medication administration record for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benzotropine to relieve which of the following adverse effects?

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

A nurse is assessing a school age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate?

Aggression toward animals Aggression toward people and animals is an expected characteristic of a child who has conduct disorder.

A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate?

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

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer.

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?

Arrange one-to-one observation of the client.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse,. "I hear voices telling me what to do." Which of the following actions should the nurse take?

Ask the client what the voices are saying.

A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take?

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

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take?

Ask the family member if she has any thoughts or questions about the treatment plan. This action involves the family member and allows her a venue to communicate about the client's medication treatment plan.

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take?

Ask the family member if they have any thoughts or questions about the treatment plan.

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should there nurse take?

Assess the client for evidence of a perceptual disturbance.- The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions.

A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?

Attending a relapse prevention group several times each week The most effective strategy for relapse prevention is a 12-step program, such as Alcoholics Anonymous.

A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?

Attending a relapse prevention group several times each week-The nurse should identify that the most effective strategy for relapse prevention is a 12-step program, such as Alcoholics Anonymous. -methadone is used to treat opioid use disorder, not alcohol use disorder.-buprenorphine is used to treat opioid use disorder, not alcohol use disorder.

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?

Attention to body language

A nurse is communicating with a client in an impatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?

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

A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching?

Avoid looking directly at the light during treatment.

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?

Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

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

Clang association

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?

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

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?

Diazepam 5 mg IV bolus

A nurse in a provider's office is collecting a health history from the parent of a school age child who has been taking atomoxetine. Which of the following adverse effects reported by the parents is the priority for the nurse to reports to the provider?

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

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomexetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

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

A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first?

Determine the client's prescribed medication regimen.- The first action the nurse should take when using the nursing process is to assess the client. By determining the client's prescribed medications, the nurse can determine the cause of the hypertension, such as the client taking an MAOI to treat depression. These medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods, including wine.

A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing a spiritual assessment as part of end of life care, which of the following interventions should the nurse implement?

Discuss spiritual issues in a conversational manner. Clients receiving end-of-life care prefer that discussions of spirituality occur in ordinary conversation.

A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first?

Discuss the importance of hair with the client. The first action the nurse should take using the nursing process is to assess the client's needs. The experience of anticipatory grieving begins with acknowledging the importance of the expected loss.

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?

Do not administer the lorazepam.

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?

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

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?

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

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Emotional lability- The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions.

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?

Encourage frequent rest periods throughout the day.

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.)

Feelings of hopelessness Anhedonia Flat facial expression

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestation. The nurse should teach the partner to expect which of the following manifestations to occur first?

Frequently misplaces objects

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation. The nurse should gather supplies for endotracheal intubation since an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?

Giving away possessions Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?

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

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Hand tremors

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Hypertension

A nurse is assessing a client who has recently used cocaine. Which of the following should the nurse expect?

Hypertension Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism.

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?

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

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan?

Identify the client's trigger foods. The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand his thoughts and behavior that relate to the food. The nurse should weigh the client immediately after he wakes up and voids and prior to oral intake. The nurse should weigh the client daily for the first week and then three times per week. The nurse should limit the client's meal times to about 30 min to prevent putting excessive focus on food.

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?

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

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?

Inappropriate dress

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

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

A nurse is performing an admission assessment and notices that the client appears withdrawal and fearful with nurse-client relationship, which of the following actions should the nurse take first?

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

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?

Interview the client in a private setting.

A school nurse is assessing a school age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD)?

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

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Language delay A child who has autism spectrum disorder usually has language delay.

A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?

Nonmaleficence It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage his behavior and thereby prevent injury to others on the unit. The nurse applies the ethical principle of veracity when being truthful with clients and others.

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?

Orthostatic hypotension

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?

Orthostatic hypotension Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension. Other manifestations of anorexia nervosa include bradycardia, amenorrhea and constipation.

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

Promote the use of music to compete with the client's auditory hallucinations.

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse?

Provide frequent high-calorie snacks.

A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse?

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

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?

Refrains from manipulating others to earn dining room privileges

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?

Remove unnecessary equipment from the child's surroundings.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Report the occurrence to the charge nurse.

A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver?

Respite care

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

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

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Set realistic limits on the client's behavior.

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

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

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM?

Shuffling gait

During a client's initial interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse made based on the client's nonverbal behaviors?

The client is interested in what the nurse is saying. The client's posture and eye contact demonstrate that she is interested in the interview and what the nurse is saying.

A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? PT INFO Vital Signs Temperature 37.3° C (99.2° F) Pulse 88/min Respiratory rate 18/min Blood pressure 138/88 mm Hg History and Physical Client has been hospitalized for manic episodes three times in the past 2 years. Client reports nausea, vomiting, and thirst. Family reports hyperactivity, nonstop pacing, and a 5 lb weight loss in the last week. OPTIONS: Erythrocyte sedimentation rate 18 mm/hr Hemoglobin 15 g/dL Serum T4 5 mcg/dL Sodium level 125 mEq/L

Sodium level 125 mEq/L In the presence of low sodium levels, renal excretion of lithium is reduced and the client is at risk for lithium toxicity. Therefore, the nurse should report this laboratory value to the provider.

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine?

St. John's wort

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

Substance use disorder

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

Substance use disorder Clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

A nurse is caring for an older client who has dementia and has wandered into the day room looking for her decreased partner. Which of the following should the nurse take?

Talk with the client about activities she enjoyed with her partner. Talking about positive experiences can help distract the client from her disorientation.

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?

Talk with the client about activities they enjoyed with their partner.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists in orienting the client to reality?

Talk with the client about scheduled daily activities. Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day.

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

The client is interested in what the nurse is saying.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash. The client experiences a situational crisis when an unexpected event occurs. Adventitious crisis is when an external disaster occurs. Maturational crisis is curing a natural life event.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash. -The client experiences a situational crisis when an unexpected event occurs.

A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?

The client reports a sore throat. Clozapine can lead to a potentially fatal blood disorder known as agranulocytosis. Agranulocytosis is a severe drop in a client's WBCs, which leaves the client highly susceptible to infection. The nurse should withhold the medication for any indications of infection and notify the provider. Constipation is an expected adverse effect of clozapine. Increasing fluid and fiber intake or the administration of stool softeners will decrease the risk for constipation. Orthostatic hypotension is an expected adverse effect of clozapine. Encouraging the client to rise slowly when transitioning from a sitting to a standing position will help to prevent falls and will increase client safety. Weight gain is an expected adverse effect of clozapine. Following a calorie-controlled diet and participating in regular exercise can help minimize weight gain.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

The client reports an inability to breathe easily.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

The client will refrain from self-mutilation.

A client is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

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

A charge nurse is developing an educational program about schizophrenia. Which of the following manifestations should the nurse include as a negative symptom of schizophrenia?

Thought blocking Thought blocking is a negative symptom of schizophrenia. This manifestation is a sudden interruption in a client's thought processes, usually due to an internal stimulus. The client may abruptly stop talking mid-sentence.

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%

A charge nurse is planning a teaching regarding the code of ethics for registered nurses. Which of the following information should the nurse include in the teaching?

The right to treatment ensures individualized care. The Hospitalization of the Mentally Ill Act of 1964 requires that clients admitted to an inpatient mental health facility have a right to individualized treatment. Client confidentiality protects clients while they are alive and after death. Privileged communication protects professional staff from divulging communication between clients and professional staff.

A nurse is caring for a client who has admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication?

Urinary retention Urinary retention is an anticholinergic effect of amitriptyline. Therefore, the nurse should monitor for this as an adverse effect.