Mental Health ATI Edition 11 Reveiw

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 the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1.5 mL Follow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? mLStep 2: What is the dose the nurse should administer? Dose to administer = Desired 7.5 mgStep 3: What is the dose available? Dose available = Have 5 mgStep 4: Should the nurse convert the units of measurement? NoStep 5: What is the quantity of the dose available? 1 mLStep 6: Set up an equation and solve for X.Desired × QuantityX = Have7.5 mg × 1 mLX mL = 5 mgX mL = 1.5Step 7: Round if necessary.Step 8: Determine whether the amount to administer makes sense. If there are 5 mg/mL and the prescription reads 7.5 mg, it makes sense to administer 1.5 mL. The nurse should administer diazepam 1.5 mL IV bolus.

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antipsychotics? (select all that apply) A. auditory hallucinations B. withdrawal from social situations C. delusions of grandeur D. severe agitation E. anhedonia

A, C, D. correct. positive symptoms of schizophrenia are effectively treated with 1st generation antipsychotics

A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? A. "I am going to order a wheelchair for when I'm unable to walk." B. "I am going to stop paying my bills since I won't be around much longer." C. "I wish you would go take care of somebody who actually needs you." D. "I am sure I'm going to be able to continue to care for myself without help."

A. "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 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? A. "I should eat a regular diet with normal amounts of salt and fluids." B. "I should discontinue the lithium when I begin to feel better." C. "I need to be careful to avoid becoming addicted to the lithium." D. "I can skip a dose of medication if my stomach is upset."

A. "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 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? A. "If you do my homework for me, I won't bother you for the rest of the day." B. Mom is always upset." C. "It's not the children's fault. It's mine." D. "It's your fault that we're having problems as a family."

A. "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 nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? A. "It appears as though you would like to open the door." B. "You will feel more comfortable after you've been here for a while." C. "It is okay to not want to be here." D. "You really shouldn't be pushing on the door."

A. "It appears as though you would like to open the door." This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

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? A. Allow the client time to formulate an answer. B. Prompt the client to give a response. C. Move on to the next client. D. Offer the client a suggestion for a goal.

A. Allow the client time to formulate an answer. Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

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? A. Arrange one-to-one observation of the client. B. Encourage interaction with the client's peers. C. Administer medication for depressive disorder. D. Encourage the client to attend a support group.

A. Arrange one-to-one observation of the client. The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety.

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? A. Do not administer the lorazepam B. Request IV lorazepam C. Request another nurse attempt to administer the lorazepam D. Place the lorazepam in the client's food

A. 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 refusal.

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? A. Encourage the client to drink 125 mL of fluid each hour while awake. B. Allow the client to eat independently in their room. C. Weigh the client twice weekly. D. Measure the client's vital signs once each day.

A. Encourage the client to drink 125 mL of fluid each hour while awake. The nurse should encourage the client to drink 125 mL of fluid each waking hour to maintain hydration.

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.) A. Feelings of hopelessness B. Pressured speech C. Grandiosity D. Anhedonia E. Flat facial expression

A. Feelings of hopelessness is correct. The nurse should document feelings of hopelessness as a clinical manifestation of major depressive disorder. D. Anhedonia is correct. The nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorder. E. Flat facial expression is correct. The nurse should document a flat facial expression as a clinical manifestation of major depressive disorder.

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? A. Gather supplies for endotracheal intubation. B. Administer a beta blocker intravenously. C. Position the client in a low-Fowler's position. D. Place a cooling blanket over the client.

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

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? A. Increased creatine phosphokinase (CPK) B. Increased low-density lipoproteins (LDL) C. Decreased fasting blood glucose D. Decreased aspartate aminotransferase (AST)

A. 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 on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? A. Inform the client that this admission is confidential. B. Introduce the client to other clients in the day room .C. Assist the client in facilitating behavioral change. D. Determine coping strategies that the client has used in the past.

A. Inform the client that this 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 client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take? A. Move the client who has bipolar disorder to a private room. B. Administer sleep medication to the client who has bipolar disorder. C. Move the client who has severe depression to a private room. D. Administer sleep medication to the client who has severe depression.

A. Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.

A nurse is planning care for a client who has made repeated physical threats toward 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? A. Nonmaleficence B. Veracity C. Justice D. Autonomy

A. 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 their behavior and thereby prevent injury to others on the unit.

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.) A. Occupational therapy B. Meal delivery services C. Speech-language pathologist D. Physical therapy E. Home health services

A. Occupational therapy B. Meal delivery services D. Physical therapy E. Home health services Occupational therapy is correct. An occupational therapist can assist the client to perform ADLs. Meal delivery services is correct. Meal delivery services are necessary due to the client's difficulty performing ADLs. Physical therapy is correct. A physical therapist can assess the client's mobility needs and assist with ADLs. Home health services is correct. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

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? A. Promote the use of music to compete with the client's auditory hallucinations. B. Inform the client that the auditory hallucinations are not real. C. Avoid asking the client if they are experiencing auditory hallucinations. D. Instruct the client on the use of voice recognition regarding the auditory hallucinations.

A. Promote the use of music to compete with the client's auditory hallucinations. Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level.

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? A. St. John's wort B. Saw palmetto C. Echinacea D. Ginkgo

A. St. John's wort St. John's wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome.

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? A. The client is interested in what the nurse is saying. B. The client is attempting to manipulate the nurse. C. The client is physically attracted to the nurse. D. The client needs to feel accepted by the nurse.

A. The client is interested in what the nurse is saying. The client's posture and eye contact demonstrates an interest in the interview and what the nurse is saying.

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? A. The client needs excessive external input to make everyday decisions. B. The client demonstrates a dedication to their job that excludes time for leisure activities. C. The client adheres to a rigid set of rules. D. The client has difficulty starting new relationships unless they feel accepted.

A. The client needs excessive external input to make everyday decisions. Clients who have dependent personality disorder need excessive input from others to make everyday decisions.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? A. The client recently lost a grandparent in a motor vehicle crash. B. The client's town was hit by a tornado. C. The client's youngest child is leaving for college. D. The client is ambivalent about their upcoming retirement.

A. 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 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? A. Total body fat 8.7% B. Potassium 3.6 mEq/L C. Temperature 36.1° C (96.9° F) D. Heart rate 54/min

A. Total body fat 8.7% The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider.

A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? The client reports a history of anxiety; diagnosed with Alzheimer's disease 2 months ago. The client's partner died 6 months ago. Reports decreased appetite, low energy levels, and insomnia for several weeks; some memory loss. A. Use a screening tool to evaluate the client for depression. B. Ask the provider to decrease the dosage of the client's blood pressure medication. C. Instruct the client to decrease intake of vitamin B12. D. Suggest the client go for a brisk walk 20 min just before bedtime.

A. Use a screening tool to evaluate the client for depression. Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? A. WBC count 2,500/mm3 B. Hgb 11.5 mg/dL C. Platelets 150,000/mm3 D. RBC count 3.5 million/mm3

A. WBC count 2,500/mm3 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

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? A. clang association B. word salad C. neologism D. echolalia

A. 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 a similar sound.

A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medications will improve your ability to maintain abstinence from alcohol."

A. correct. Carbamazepine is used during withdrawal to decrease the risk for seizures.

A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states, "I grind my teeth during the night, which causes pain in my mouth." The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply) A. Concurrent administration of buspirone B. administration of a different SSRI C. use of a mouth guard D. changing to a different class of antianxiety medication E. increasing the dose of paroxetine

A. correct. Concurrent administration of a low-dose of buspirone is an effective measure to manage the adverse effect of paroxetine. C. correct. using a mouth guard during sleep can decrease the risk for oral damage resulting from bruxism. D. correct. Changing to a different class of antianxiety medication that does not have the adverse effect of bruxism is an effective measure

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. administer the next dose of lithium carbonate as scheduled B. prepare for administration of aminophylline C. notify provider for a possible increase in the dosage of lithium carbonate D. request a stat repeat of the client's lithium blood level

A. correct. During a manic episode the lithium blood level should be 0.8 to 1.4 mEq/L. It is appropriate to administer the next dose as scheduled.

A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply) A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence" D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be prescribed and dispensed by an approved treatment center."

A. correct. Methadone is an oral opioid agonist that replaces the opioid to which the client has physical dependence. B. correct. methadone administration prevents abstinence syndrome from occurring C. correct. Methadone substitution is used for both opioid withdrawal and long term-maintenance E. Correct. Due to the risk for physical dependence, methadone is required to be prescribed and dispensed by an approved treatment center.

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I should tell the client about the likelihood of insomnia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder" D. "Sexual dysfunction is a common adverse effect of this medication."

A. correct. Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine.

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following meds? (Select all that apply) A. olanzapine B. quetiapine C. aripiprazole D. clozapine E. asenapine

A. correct. Olanzapine is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases the risk for agitation associated with an injection. C. correct. aripiprazole is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. D. correct. clozapine is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. E. correct. asenapine is available in sublingual tablet, which is appropriate for clients who have difficulty swallowing oral tablets.

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. crea and BUN C. WBC and granulocyte counts D. blood sodium and potassium

A. correct. Routine monitoring of liver function tests is necessary due to the risk of hepatotoxicity.

A nurse is working with a client who has recently lost a guardian. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (select all that apply) A. interpersonal relationships B. culture C. birth order D. religious beliefs E. prior experience with loss

A. correct. The client's interpersonal relationships are factors which influence the client's reaction to grief and ability to cope. B. correct. the client's culture is a factor that influences the client's reaction to grief and ability to cope. D. correct. The client's religious beliefs are factors that influences the client's reaction to grief and ability to cope. E. correct. The client's prior experience with loss is a factor that influences the client's reaction to grief and ability to cope.

A nurse is caring for a client who lost a guardian to cancer last month. The client states, "I'd still have my guardian if the doctor would have made a diagnosis sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you spoke about your feelings with a support group." C. "I understand just how you feel. I felt the same when my guardian died." D." Do other members of your family also feel this way?"

A. correct. This is a therapeutic response for the nurse to make. This response acknowledges the client's emotion and provides education on the normal grief response.

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A. "Stop screaming and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?"

A. correct. This is an appropriate therapeutic response. Setting limits and the use of physical activity to deescalate anger is an appropriate intervention.

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the new nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."

A. correct. administer prophylactic treatment for infections according to CDC.

A nurse is teaching a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include? Select all that apply. A. Bullying of others B. threats of suicide C. law breaking activities D. narcissistic behavior E. flat affect

A. correct. bullying behavior is an expected finding of conduct disorder B. correct. suicidal ideations is an expected finding of conduct disorder C. correct. law and/or rule breaking behavior is an expected finding of conduct disorder.

A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. eat a diet high in fiber B. check temperature daily C. take medication first thing in the morning before eating D. add extra calories to the diet as between meal snacks

A. correct. eating a high diet in fiber will decrease constipation, an anticholinergic effect associated with TCA issue

A nurse is assessing a client who has illness anxiety disorder. Which of the following are expected for this disorder? (select all that apply) A. obsessive thoughts about disease B. history of childhood abuse C. avoidance of health care providers D. depressive disorder E. narcissistic personality

A. correct. obsessive thoughts about the disease is an expected finding in a client who has illness anxiety disorder. B. correct. a history of childhood abuse is an expected finding in a client who has illness anxiety disorder. C. correct. avoidance of health care providers is an expected finding in clients who have illness anxiety disorder of the care-avoidant type. D. correct. a depressive disorder is an expected finding in a client who has illness anxiety disorder.

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? Select all that apply. A. Conducting a suicide risk screening on all new clients B. creating a support group for family members of clients who completed suicide C. educating high school teens about suicide prevention D. initiating one on one observation for a client who has current suicidal ideations E. teaching middle school educators about warning indicators of suicide

A. correct. primary interventions include suicide prevention through the use of screenings to identify individuals at risk. Conducting a suicide risk screening on all new clients is an example of a primary intervention. C. correct. Primary interventions include suicide prevention through the use community education. Educating high school teens about suicide prevention is an example of a primary intervention. D. correct. primary interventions include suicide prevention through the use community education period educating middle school teachers the recognize the warning indicators of suicide is an example of a primary intervention.

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (select all that apply) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self-esteem."

A. correct. resentment is an emotion that can be associated with normal grief B. correct. withdrawal is an emotion that can be seen with normal grief. C. correct. somatic manifestations can be associated with normal grief.

A nurse is teaching the guardians of a child who has autism spectrum disorder about indications of imipramine toxicity. Which of the following should the nurse include in teaching? (select all that apply) A. seizures B. agitation C. photophobia D. dry mouth E. irregular phase

A. correct. seizures are an indication of TCA toxicity B. correct. agitation is an indication of TCA toxicity. E. correct. irregular pulse can indicate a dysrhythmia which is an indicator of TCA toxicity

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. death of a child 2 months ago B. recent weight loss of 30lbs C. retirement 1 year ago D. history of migraine headaches

A. correct. the death of a child at 2 months ago is an acute stressor that places the client at risk for conversion disorder.

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? Select all that apply. A. "my family will be better off if I'm dead" B. "the stress in my life is too much to handle" C. "I wish my life was over" D. "I don't feel like I can ever be happy again" E. "if I kill myself then my problems will go away"

A. correct. this statement is an overt comment about suicide in which the client directly talks about their perception of an outcome of their death. Assess the client further for a suicide plan. C. correct. this statement is an overt comment about suicide in which the client directly talks about their wish to no longer be alive assess the client further for a suicide plan. E. correct. this statement is an overt comment about suicide in which the client directly talks about their perception of an outcome of their completed suicide. Assess the client further for a suicide plan

A nurse is teaching a client who has a new prescription for imipramine on how to minimize anticholinergic effects. Which of the following instructions should the nurse include in teaching? (Select all that apply) A. Void just before taking the medication. B. Increase the dietary intake of potassium C. wear sunglasses when outside. D. change positions slowly when getting up. E. chew sugarless gum

A. correct. voiding just before taking the medication will help minimize the anticholinergic effects of urinary hesitancy or retention. C. correct. Wearing sunglasses when outside will help minimize the anticholinergic effects of photophobia. E. correct. chewing sugarless gum will help minimize the anticholinergic effect of dry mouth.

A nurse is caring for a client following the loss of a partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. (Select or number the stages in order of occurrence) A. developing awareness B. restitution C. shock and disbelief D. recovery E. resolution of the loss

A. developing awareness (2) B. restitution (3) C. shock and disbelief (1) D. recovery (5) E. resolution of the loss (4)

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? A. emotional lability B. self-sacrificing C. suspicious of others D. grandiosity

A. emotional lability Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances.

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? A. respite care B. partial hospitalization C. adult day care program D. geropsychiatric unit

A. respite care Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves.

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? A. shuffling gait B. hypotension C. decreased WBC count D. blurred vision

A. shuffling gait Benztropine is used to treat parkinsonism manifestations, such as shuffling gait.

A charge nurse is reviewing Kubler-Ross: Five stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in teaching? (select all that apply) A. disequilibrium B. denial C. bargaining D. anger E. depression

All are correct except, A. Remember: DABDA denial, anger, bargaining, depression, acceptance

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? A) "Cognitive reframing will help me change my irrational thoughts to something positive" B) "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate" C) "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety" D) "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety"

Answer A) "Cognitive reframing will help me change my irrational thoughts to something positive" - Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way

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

Answer A) Excessive stressors cause the client to experience distress - Distress is the result of excessive or damaging stressors (anxiety or anger)

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

Answer A. "I'm scared that you're going to leave me." - Clients who have avoidant personality disorder often have fear of abandonment

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of safe houses and shelters B. Encourage the client to participate in a support group for survivors of abuse C. Implement case management to coordinate community and social services D. Educate the client about the use of stress management techniques

Answer A. Advise the client about the location of safe houses and shelters - The greatest risk to this client is injury from further abuse; therefore, the priority action is to assist the client with the development of a safety plan that includes the identification of safe places to live

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (select all that apply) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

Answer A. Difficulty in getting along with other members of a group - Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types C. Display of defense mechanisms when routines are changed - Maladaptive response to stress is a personality characteristic that can be seen in clients E. Difficulty understanding why it is inappropriate to have a personal relationship with staff - Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? A. Install extra locks at the top of exit doors B. Place rugs over electrical cords C. Put cleaning supplies on the top of a shelf D. Place the client's mattress on the floor E. Install light fixtures above stairs

Answer A. Install extra locks at the top of exit doors - Placing door locks up high where they are difficult to reach can prevent exiting the home and wandering outside D. Place the client's mattress on the floor - Placing the client's mattress on the floor reduces the risk for falls out of bed E. Install light fixtures above stairs - Stairs should have adequate lighting to reduce the risk for falls

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

Answer B) Use assertiveness techniques - Assertive communication allows the client to assert their feelings and then make a change in the situation

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over-the-counter acetaminophen while on donepezil." B. "You should take this medication before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

Answer B. "You should take this medication before going to bed at the end of the day." - Clients should take donepezil at the end of the day, just before going to bed, with or without food

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

Answer B. Family report of personality changes - The client who has delirium can experience rapid personality changes C. Hallucinations - The client who has delirium can have perceptual disturbances (hallucinations and illusions) E. Restlessness - The client who has delirium commonly exhibits restlessness and agitation

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

Answer B. Fine tremors of both hands - Fine tremors of both hands is an expected finding of alcohol withdrawal D. Vomiting - Vomiting is an expected finding of alcohol withdrawal E. Restlessness - Restlessness is an expected finding of alcohol withdrawal

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply) A. Amenorrhea B. Hypokalemia C. Yellowing of the skin D. Slightly elevated body weight E. Presence of lanugo on the face

Answer B. Hypokalemia - Hypokalemia is an expected finding of purging-type bulimia nervosa D. Slightly elevated body weight - Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect B. Intentionally causing someone to fall is an example of physical violence C. Striking a sexual partner is an example of sexual violence D. Failure to provide a stimulating environment for normal development is emotional abuse

Answer B. Intentionally causing someone to fall is an example of physical violence - Physical violence occurs when physical pain or harm is directed toward another individual

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (select all that apply) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

Answer B. Respiratory distress - Respiratory distress is an expected finding of shaken baby syndrome C. Retinal hemorrhage - Retinal hemorrhage is an expected finding of shaken baby syndrome D. Altered level of consciousness - An altered level of consciousness is an expected finding of shaken baby syndrome E. Increase in head circumference - An increase in head circumference is an expected finding of shaken baby syndrome

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (Select all that apply) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

Answer B. Round burn marks on forearms - Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse E. Areas of ecchymosis on torso - Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification

Answer B. Splitting - Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time

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

Answer C) Asks for group suggestions of techniques and then support discussion - Democratic leadership supports group interaction and decision making to solve problems

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

Answer C) Bipolar disorder with rapid cycling - ECT is indicated for the treatment of bipolar disorder with rapid cycling

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

Answer C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." - This statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self-esteem and self-image.

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCF is due to which of the following underlying reasons? A. Narcissistic behavior B. fear of rejection from staff C. attempt to reduce anxiety D. adverse effect of antidepressant medication

Answer C. Attempt to reduce anxiety: clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (select all that apply) A. Demonstrates extreme anxiety when placed in a social situation B. Often engages in magical thinking C. Attempts to convince other clients to relinquish their belongings D. Becomes agitated if personal area is not neat and orderly E. Blames others for personal past and current problems

Answer C. Attempts to convince other clients to relinquish their belongings - Exploitation and manipulation of others is an expected finding of antisocial personality disorder E. Blames others for personal past and current problems - Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file B. Instruct the client's partner to offer finger foods to increase oral intake C. Provide information on resources for respite care D. Schedule the client for placement of an enteral feeding tube

Answer C. Provide information on resources for respite care - Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiving responsibilities

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

Answer D) "I will receive a muscle relaxant to protect me from injury during ECT" - a muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity

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

Answer D) "I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks" - TMS is commonly prescribed 3 to 5 times a week for the first four to six weeks

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? A) "You really should complete your own work. I don't think it's right to expect me to complete your responsibilities" B) "Why do you expect me to finish your work? You must realize that I have my own responsibilities" C) "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor" D) "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities"

Answer D) "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities" - This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

Answer D. "I am your nurse. Let's walk together to your room." - It is appropriate to introduce oneself with each new interaction and to promote reality in a calm, reassuring manner

A nurse is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following actions should the nurse include in the client's plan of care? A. Allow the client to select preferred meal times B. Establish consequences for purging behavior C. Provide the client with a high-fat diet at the start of treatment D. Implement one-to-one observation during meal times

Answer D. Implement one-to-one observation during meal times - Closely monitor the client during and after meals to prevent purging

A nurse is caring for an adolescent client who has anorexia nervosa with recent parid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

Answer A. "Life isn't worth living if I gain weight." - This statement reflects the cognitive distortion of catastrophizing because the client's perception of their appearance or situation is much worse than their current condition

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"

Answer A. "What is your relationship like with your family?" - A nursing history of a client who has anorexia nervosa should include an assessment of family and interpersonal relationships C. "Would you describe your current eating habits?" - A nursing history of a client who has anorexia nervosa should include an assessment of the client's current eating habits E. "Can you discuss your feelings about your appearance?" - A nursing history of a client who has anorexia nervosa should include an assessment of the client's perception of the issue

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (select all that apply) A. "When did you start hearing these things?" B. "The voices are not real, or else we would both hear them" C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?" E. "Why are the voices talking to only you?"

Answer A. "When did you start hearing these things?" - Ask the client directly about the hallucination C. "It must be scary to hear voices." - Focus on the client's feeling rather than agreeing with the client's hallucination D. "Are the voices you hear telling you to hurt yourself?" - Assess for command hallucination and the client's risk for injury to self or others

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (select all that apply) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat effects

Answer A. Auditory hallucination - Hallucinations are an example of a positive symptom C. Use of clang associations - Alterations in speech are an example of a positive symptom D. Delusion of persecution - Delusions are an example of a positive symptom E. Constantly waving arms - Bizarre motor movements are an example of a positive symptom

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates an understanding of the teaching? (Select all that apply) A. "We need to understand that our sibling is responsible for their disorder." B. "Eliminating codependent behavior will promote recovery." C. "Our sibling should participate in an AI-Anon group to assist with recovery." D. "The primary goal of treatment is abstinence from substance use." E. "Our sibling needs to discuss personal feelings about substance use to help with recovery."

Answer B. "Eliminating codependent behavior will promote recovery." - Families should be aware of codependent behavior (enabling) that can promote substance use rather than recovery D. "The primary goal of treatment is abstinence from substance use." - Abstinence is the primary treatment goal for a client who has a substance use disorder E. "Our sibling needs to discuss personal feelings about substance use to help with recovery." - Clients must acknowledge their feelings about substance use as part of a substance use recovery program

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."

Answer B. "I am here to provide care and cannot accept this from you." - This statement is matter-of-fact and concise and is a therapeutic response to a client who has bipolar disorder

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

Answer B. "I am no one, and everyone is me." - This comment indicates the client is experiencing a loss of identity or depersonalization

A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior

Answer B. Ask the client, "Are you seeing something on the ceiling?" - Ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (select all that apply) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse

Answer B. Difficulty sleeping can indicate a relapse. - The client should be alert for sleep disturbances, which can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. - The client who has bipolar disorder can participate in psychotherapy to help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse - The onset of anhedonia, the inability to feel pleasure, is a manifestation of depression which can indicate a relapse of bipolar disorder.

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit B. Initiate one-to-one observation of the client. C. Focus the client on reality D. Notify the provider of the client's statement

Answer B. Initiate one-to-one observation of the client .- A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one-to-one observation is the first action the nurse should take.

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

Answer C. "ECT is effective for clients who are experiencing severe mania." - ECT is appropriate for the treatment of severe mania associated with bipolar disorder.

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit-setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

Answer C. "I should practice limit-setting to help prevent client manipulation." - When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide B. Bupropion C. Disulfiram D. Carbamazepine

Answer C. Disulfiram - The nurse should expect to administer disulfiram to help the client maintain abstinence from alcohol

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place, and person B. Offer fluids and nourishing diet as tolerated C. Implement seizure precautions D. Encourage participation in group therapy sessions

Answer C. Implement seizure precautions- The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention

A nurse is planning a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect B. Older adults commonly use rationalization to cope with a substance use disorder C. Older adults are at an increased risk for substance use following retirement D. Older adults develop substance use to mask manifestations of dementia

Answer C. Older adults are at an increased risk for substance use following retirement - Retirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step-by-step instructions during hygiene activities. D. Monitor the client for escalating behavior.

Answer D. Monitor the client for escalating behavior. - Monitoring for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 5 are at greater risk for abuse" B. "Substance use disorder does not increase the risk for violence" C. "Entering an intimate relationship increases the risk for violence" D. "Pregnancy increases the risk for violence from a spouse or partner"

Answer D. "Pregnancy increases the risk for violence from a spouse or partner"- Pregnancy tends to increase the likelihood of violence from a spouse or partner

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? Select all that apply. A. Avoid thinking about the incident when it is over. B. Take breaks during the incident for food and water. C. Debrief with others following the incident. D. Avoid displays of emotion in the days following the incident. E. Take advantage of offered counseling.

Answer. B, C, E. Taking breaks and remembering to drink water and eat nutritious Foods while working during a traumatic incident can help prevent development of a trauma-related disorder. Debriefing with others following a traumatic incident can help prevent development of a trauma related disorder. Taking advantage with counseling offered by an employer or others can help prevent development of a trauma related disorder.

A nurse working on an acute mental health unit is caring for a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? Select all that apply. A. Difficulty concentrating on tasks B. obsessive need to talk about the traumatic event C. negative self-image D. recurring nightmares E. diminished reflexes

Answer: A,C,D. Manifestations of PTSD include the inability to concentrate on or complete tasks. Manifestations of PTSD include feeling guilty and having a negative self-image. Manifestations of PTSD include recurring nightmares or flashbacks.

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

Answer: A) Aversion therapy - Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior

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

Answer: A) Discussing ways to use new behavior - Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase

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

Answer: A) Educational groups - Education groups are services provided in a community mental health facility B) Medication dispensing programs - Medication dispensing programs are services provided in a community mental health facility C) Individual counseling programs - Individual counseling programs are services provided in a community mental health facility. E) Family therapy - Family therapy is a service provided in a community mental health facility

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

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

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

Answer: A) Priority restructuring - Priority restructuring is a cognitive reframing technique B) Monitoring thoughts - Monitoring thoughts is a cognitive reframing technique D) Journal keeping - Journal keeping is a cognitive reframing technique

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbance

Answer: A, D, E. Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 6 months. generalized anxiety disorder is characterized by restlessness. Generalized anxiety disorder is characterized by the presence of sleep disturbances.

A nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. " Tell me about how you're feeling right now. " B. "You should focus on the positive things in your life to decrease your anxiety." C. " Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

Answer: A. " Tell me about how you're feeling right now." Asking an open-ended question is therapeutic and assists the client in identifying and anxiety.

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Assess the client's risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

Answer: A. Assess the client's risk for self-harm. The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. Therefore, the first action to take is to assess the client's risk for self-harm to ensure that the client is provided with a safe environment.

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

Answer: B) "The therapist will focus on my past relationships during our sessions." - Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder

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

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

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

Answer: B) Denial - This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real

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

Answer: B) False imprisonment - A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of staff.

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

Answer: B) Identify the client's perception of their mental health status - Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important information about the client's psychosocial history

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

Answer: B) Manipulation - Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda

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

Answer: B) Moderate - Moderate anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious

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

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

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A) The client asks the nurse if they will go out to dinner together B) The client accuses the nurse of being controlling just like an ex-partner C) The client reminds the nurse of a friend who died from substance toxicity D) The client becomes angry and threatens to engage in self harm

Answer: B) The client accuses the nurse of being controlling just like an ex-partner - When a client views the nurse as having characteristics of another person who has been significant to their personal life (an ex-partner) this indicates transference

A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make A) "I feel very sorry for the loneliness you must be experiencing." B) "Suicide is not the appropriate way to cope with loss." C) "Losing someone close to you must be very upsetting." D) "I know how difficult it is to lose a loved one"

Answer: C) "Losing someone close to you must be very upsetting." - This statement is an empathetic response that attempts to understand the client's feelings

A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? A) "You and a group of other clients will meet to discuss your treatment plans." B) "Community meetings have a specific agenda that is established by staff." C) "You and the other clients will meet with staff to discuss common problems." D) "Community meetings are an excellent opportunity to explore your personal mental health issues

Answer: C) "You and the other clients will meet with staff to discuss common problems." - Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit

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

Answer: C) A client who has borderline personality disorder and assaulted a homeless man with a metal rod - A client who is a current danger to self or others is a candidate for temporary emergency admission

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

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

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A) A member who praises input from other members B) A member who follows the direction of other members C) A member who brags about accomplishments D) A member who evaluates the group's performance toward a standard

Answer: C) A member who brags about accomplishments - An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals.

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

Answer: C) Attending a partial hospitalization program - A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present

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

Answer: C) Establishing rehabilitation programs to decrease the effects of depression - Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness

A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy? A) Demonstrate riding in an elevator, and then ask the client to imitate the behavior B) Advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator C) Gradually expose the client to an elevator while practicing relaxation techniques D) Stay with the client in an elevator until the anxiety response diminishes

Answer: C) Gradually expose the client to an elevator while practicing relaxation techniques- Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure. Relaxation techniques suppress the anxiety response

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

Answer: C) Subgroup - A subgroup is a small number of people within a larger group who function separately from that group

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? A) Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding knife B) Keep the client's communication confidential, but watch the client and their roommate closely C) Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D) Report the incident to the health care team, but do not inform the client of the intention to do so

Answer: C) Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others - The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue

A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A) The nurse discusses the client's weight loss during a health care meeting B) The nurse examines their own personal feelings about clients who have anorexia nervosa C) The nurse asks the client about personal body image perception D) The nurse presents an educational session about anorexia nervosa to a large group of adolescents

Answer: C) The nurse asks the client about personal body image perception - The nurse's one-on-one communication with the client is an example of interpersonal communication

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of the derealization? A. The client describes a feeling of floating above the ground. B. The client has suspicions of being targeted in order to be killed and robbed. C. The client states that the furniture in the room seems to be small and far away. D. The client cannot recall anything that happened during the past two weeks.

Answer: C. The client states that the furniture in the room seems to be small and far away. Stating that one's surroundings are far away or unreal in some way is an example of derealization.

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

Answer: D) "I should say the first thing that comes to my mind."- Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A) "I think your child is getting better. What have you noticed?" B) "I'm sure everything will be okay. It just takes time to heal." C) "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D) "I understand you're concerned. Let's discuss what concerns you specifically."

Answer: D) "I understand you're concerned. Let's discuss what concerns you specifically." - This therapeutic response reflects upon, and accepts, the caregivers' feelings, and it allows them to clarify what they are feeling

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

Answer: D) Monitor the client for adverse effects of medications - Monitoring adverse effects of medications is an example of a psychobiological intervention

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

Answer: D) intonation - Identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings

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

Answer: D) restating - Restating allows the nurse to repeat the main idea expressed

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change the behavior C. Distract the client with a television show D. Stay with the client and remain quiet

Answer: D. Stay with the client and remain quiet. During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli.

A nurse is collecting an admission history for a client who has acute stress disorder. Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident. B. The client expresses heightened Elation about what is happening. C. The client remembers first noticing manifestations of the disorder six weeks after the traumatic incident occurred. D. The client expresses a sense of unreality about the traumatic incident.

Answer: D. The client expresses a sense of unreality about the traumatic incident. the client who has acute stress disorder often expresses dissociative manifestations regarding the event, which includes a sense of unreality.

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care? A. Teach the client to recognize how stress brings on a personality change in a client. B. Repeatedly percent the client with information about past events. C. Make decisions for the client regarding routine daily activities. D. Work with a client on grounding techniques.

Answer: D. Work with the client on grounding techniques. Grounding techniques are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization. Examples are stomping the feet, clapping the hands, or touching physical objects.

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? A. Placing the client on one to one observation B. assisting the client to perform activities of daily living C. encouraging the client to participate in counseling D. teaching a client about medication adverse effects

Answer: A. Placing the client on one to one observation. The greatest risk for a client who has major depressive disorder and comorbid anxiety is injury due to self harm. The highest priority intervention is placing the client on one to one observation.

A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder. which of the following statements by the client indicates an understanding of the teaching? A. " I can expect my problems with PMDD to be worst when I am menstruating." B. " I should have voice exercising when I am feeling depressed." C. " I am aware that my PMDD Causes me to have rapid mood swings." D. " I should increase my caloric intake with a nutritional supplement when my PMDD is active."

Answer: C. " I am aware that my PMDD cause me to have rapid mood swings." A clinical finding of PMDD is emotional lability. The client can experience rapid changes in mood.

A charge nurse is discussing the care of a client who has major depressive disorder with a newly licensed nurse. Which of the following statements by the newly-licensed nurse indicates an understanding of the teaching? A. " Care during the continuation face focuses on three team continued manifestations of MDD." B. "The treatment of MDD during the maintenance face lasts for 6 to 12 weeks." C. "The client is at greater risk for suicide during the first weeks of an MDD episode." D. " Medication and Psychotherapy are most effective during the acute phase of MDD."

Answer: C. The client is at greater risk for suicide during the first weeks of an MDD period most especially during the acute phase.

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression. Select all that apply. A. Male sex B. chronic bronchitis C. recent deaths in clients family D. family history of depression E. personal history of panic disorder

Answer: B,C,D,E. Depressive disorders are more common in a client who has a chronic medical condition. It is also more likely to occur in a client who is experiencing a high amount of stress. In addition to that, depressive disorders are more likely to occur in a client who has a family history of depression. Lastly, a history of anxiety or personality disorder increases a client's risk for depressive disorder.

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

Answers A) Voice changes - Voice changes are a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx D) Cough - Coughing is a potential adverse effect of VNSE) Neck pain- Neck pain is a potential adverse effect of VNS. However, this usually subsides within time

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

Answers B) Depressed immune system - A depressed immune system is an indicator of acute stress C) Increased blood pressure - Increased blood pressure is an indicator of acute stress E) Unhappiness - Unhappiness is an indicator of acute stress

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

Answers C) Memory loss - Transient short-term memory loss is an expected finding immediately following ECT E) Confusion - confusion is an expected finding immediately following ECT

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

Answers: A) "To assess cognitive ability, I should ask the client to count backward by sevens." - Counting backward by 7s is an appropriate technique to assess a client's cognitive ability B) "To assess affect, I should observe the client's facial expression." - Observing a client's facial expression is appropriate when assessing affect C) "To assess language ability, I should instruct the client to write a sentence." - Writing a sentence is an indication of language ability

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

Answers: B) "Client was offered 8 oz of water every hr" - The amount and frequency of fluids offered is objective data that should be documented when caring for a client in mechanical restraints C) "Client shouted obscenities at assistive personnel" - A description of the client's verbal communication is objective data that should be documented when caring for a client in mechanical restraints D) "Client received chlorpromazine 15 mg by mouth at 1000" - The dosage and time of medication administration is objective data that should be documented when caring for a client in mechanical restraints

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

Answers: B) Define the purpose of the group - During the initial phase, identify the purpose of the group C) Discuss termination of the group - During the initial phase, discuss termination of the group E) Establish an expectation of confidentiality within the group - During the initial phase, set the tone of the group, including an expectation of confidentiality

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

Answers: B) Discuss prior use of coping mechanisms with the client - Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor D) Demonstrate a calm manner while using simple and clear direction - Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others

A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following information is appropriate to include in the discussion? (Select all that apply) A) The DSM-5 includes client education handouts for mental health disorders. B) The DSM-5 establishes diagnostic criteria for individual mental health disorders. C) The DSM-5 indicates recommended pharmacological treatment for mental health disorders D) The DSM-5 assists nurses in planning care for client's who have mental health disorders E) The DSM-5 indicates expected assessment findings of mental health disorders

Answers: B) The DSM-5 establishes diagnostic criteria for individual mental health disorders. - The DSM-5 establishes diagnostic criteria for mental health disorders D) The DSM-5 assists nurses in planning care for client's who have mental health disorders - Nurses use the DSM-5 to plan, implement and evaluate care for client's who have mental health disorders E) The DSM-5 indicates expected assessment findings of mental health disorders The DSM-5 identifies expected findings for mental health disorders

A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (select all that apply) A) The needs of both participants are met B) An emotional commitment exists between the participants C) It is goal-directed D) Behavioral change is encouraged E) A termination date is established

Answers: C) It is goal-directed - A therapeutic nurse-client relationship is goal-directed D) Behavioral change is encouraged- A therapeutic nurse -client relationship encourages positive behavioral change E) A termination date is established- a therapeutic nurse -client relationship has an established termination date

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will spend extra time at work to keep from feeling depressed." B. "I will talk about my feelings with a close friend." C. "I will be able to learn how to prevent my partner's attacks." D. "I will use meditation instead of taking my antidepressant."

B. "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 is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? A. "You probably want to hold your baby." B. "I'll stay with you just in case you want to talk." C. "I know how you must be feeling." D. "It hurts now, but things will be better soon."

B. "I'll stay with you just in case you want to talk." This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.

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? A. "I'm relieved now that my financial affairs are in order." B. "It is easier to talk about my feelings now." C. "Suddenly I have enough energy to do anything I want." D. "Thank you for always taking such good care of me."

B. "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 guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? A. "This disease will increase our child's risk for high blood pressure." B. "It is important for our child to have regular dental checkups." C. "We need to weigh our child daily for several weeks, then once per week." D. "Bleeding during our child's periods will increase because of this disease."

B. "It is important for our child to have regular dental checkups." For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa

A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? A. "She works so hard at ballet. Will she still be able to perform?" B. "She won't let me take the trash from her room. I'm concerned about what she has in there." C. "She told me she was tired, so I did her chores for her today." D. "She is happier with her appearance now that she's lost some weight."

B. "She won't let me take the trash from her room. I'm concerned about what she has in there." The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.

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? A. "Succinylcholine will enhance the therapeutic effects of this treatment." B. "Succinylcholine is given to reduce muscle movements during therapy." C. "Succinylcholine will decrease the anxiety level that you might experience with this treatment." D. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure."

B. "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 a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? A. "You might notice an increase in saliva while taking this medication." B. "You might experience difficulties with sexual functioning while taking this medication." C. "You should expect an improvement in symptoms of depression in 3 to 4 days. "D. "You may notice a temporary ringing in the ears when starting this medication."

B. "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 counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A. You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C. "You don't want to look at yourself because you think you are fat." D. "You and I can work together to overcome your fears of gaining weight."

B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

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 findings indicating lithium toxicity? A. A client who has a fasting blood glucose level of 80 mg/dL B. A client who has a sodium level of 128 mEq/L C. A client who has a BUN of 18 mg/dL D. A client who has a potassium level of 3.6 mEq/L

B. A client who has a sodium level of 128 mEq/L A sodium level of 128 mEq/L should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level.

A nurse is caring for a group of clients. Which of the following findings should the nurse report? A. A client who is taking clozapine and has a WBC count of 7,500/mm3 B. A client who is taking lamotrigine and has developed a rash C. A client who is taking valproate and has a platelet count of 150,000/mm3 D. A client who is taking lithium and has a lithium level of 1.2 mEq/L

B. A client who is taking lamotrigine and has developed a rash Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication (Steven Johnson Syndrome) and report this finding immediately.

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? A. A school-age child who has bruises on the knees B. An older adult client who is bedbound and has a stage IV pressure ulcer C. An adolescent who has a vaginal candida infection D. A young adult who is pregnant and has a sprained ankle

B. 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 facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? A. Tell the client to talk less or risk being removed from the meeting. B. Ask group members to discuss their feelings about this client's monopolizing behavior. C. End the group meeting and take the client aside to discuss the disruptive behavior. D. Focus on other group members and ignore the client who is doing all the talking.

B. Ask group members to discuss their feelings about this client's monopolizing behavior. This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Orient the client to person, place, and time. B. Assist the client with deep-breathing exercises. C. Calm the client by using therapeutic touch. D. Have the client sit alone in a quiet room.

B. Assist the client with deep-breathing exercises. Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

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 postdischarge activities should the nurse plan to include? A. Taking the oral medication buprenorphine to prevent alcohol use B. Attending a relapse prevention group several times each week C. Beginning a methadone treatment program at a local center D. Living with their parent, who has promised to keep them away from alcohol

B. 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.

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? A. Somnolence B. Blood pressure 154/96 mm Hg C. Pinpoint pupils D. Blood glucose 210 mg/dL

B. Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to experience diarrhea while taking this medication." B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

B. Correct. Sedation is an adverse effect of amitriptyline during the first few weeks of therapy.

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? A. Additional acute episodes of depression are unlikely following inpatient care. B. Early identification of changes, such as decreased social involvement, is important. C. Medication compliance will prevent further need for inpatient hospitalization. D. It is helpful to regularly reinforce to the client that things will get better.

B. 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 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? A. Have the client participate in a morning aerobics group. B. Encourage frequent rest periods throughout the day. C. Provide a distraction such as television at night. D. Offer the client hot chocolate at bedtime.

B. Encourage frequent rest periods throughout the day. A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? A. Provide teaching about the use of positive coping mechanisms. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

B. Establish screening programs to identify at-risk clients. This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs.

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in affect within 30 to 60 min after taking the medication B. Greater risk of attempting suicide as affect and energy improve C. Onset of frequent, loose stools D. Development of physiologic dependence on the medication

B. Greater risk of attempting suicide as affect and energy improve The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment.

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? A. Develop a code word that means "time to go." B. Identify signs of escalation of violence. C. Have a predetermined place to go in the event of violence. D. Keep a hidden packed bag of necessities.

B. 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 their ideal body weight. Which of the following interventions should the nurse include in the plan? A. Include a liquid supplement with meals. B. Identify the client's trigger foods. C. Allow the client at least 1 hr for each meal. D. Weigh the client at bedtime each day.

B. 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 their thoughts and behavior that relate to the food.

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? A. Advise the client to take frequent sips of water. B. Instruct the client to avoid driving during initial therapy. C. Consult a dietitian for a calorie-controlled diet plan. D. Recommend that the client exercise regularly.

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

B. 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.

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? A. Behave in a friendly manner toward the client. B. Set realistic limits on the client's behavior. C. Show respect for the client's need for isolation. D. Act as a role model for assertiveness.

B. 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 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? A. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. B. The client reports an inability to breathe easily. C. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. D. The client reports having recently started smoking cigarettes.

B. The client reports an inability to breathe easily. Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider.

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? A. The client is exhibiting echolalia. B. The client reports command hallucinations. C. The client reports loss of motivation. D. The client is exhibiting blunted affect.

B. The client reports command hallucinations. The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others.

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? A. The program will help the client accept responsibility for the disorder. B. The client should obtain a sponsor before discharge for an increased chance of recovery. C. The client will need to identify individuals who have contributed to the disorder. D. The program will need a prescription from the client's provider prior to attendance.

B. The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program.

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion" B. "Acquaintance rape often involves alcohol" C. "Young adults are the typical victims of sexual assault" D. "The majority of rapists are unknown to the victims"

B. correct. Alcohol and other substances are often associated with date or acquaintance rape.

A nurse is caring for a client who is prescribed lithium therapy. The client tells of the plan to take Ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is not a good choice. Ibuprofen does not interact with Lithium." B. "Regular aspirin would be a better choice than Ibuprofen." C. "Lithium decreases the effectiveness of Ibuprofen." D. "The Ibuprofen will make your lithium level fall too low."

B. correct. Aspirin is recommended as a mild analgesic rather than Ibuprofen due to the risk for lithium toxicity.

A nurse is evaluating a client's understanding of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the teaching? A. "Taking this medication will help reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medicine." D. "Each dose of this medication should be placed under my tongue to dissolve."

B. correct. Clonidine commonly causes clients to experience dry mouth. Chewing sugarless gum is an effective method to address this adverse effect.

A nurse is assessing a client 4hrs after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indictions of serotonin syndrome? (select all that apply) A. hypothermia B. hallucinations C. muscular flaccidity D. diaphoresis E. agitation

B. correct. Hallucinations are an indication of serotonin syndrome. D. correct. Diaphoresis is an indication of serotonin syndrome. E. correct. Agitation is an indication of serotonin syndrome.

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis? A. rape B. marriage c. severe physical illness D. job loss

B. correct. Marriage is an example of a maturational crisis, which is a naturally occurring event during a life span.

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply) A. constipation B. polyuria C. rash D. muscle weakness E. tinnitus

B. correct. Polyuria is an early indication of lithium toxicity. D. correct. Muscle weakness is an early indication of lithium toxicity.

A nurse is assessing a four year old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess? A. Impulsive behavior B. Repetitive counting C. destructiveness D. somatic problems

B. correct. Repetitive actions and strict routines are an indication of autism spectrum disorder

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? Select all that apply. A. lithium carbonate B. Paroxetine C. risperidone D. haloperidol E. lorazepam

B. correct. SSRI Anti depressants may be prescribed to decrease the anxiety and depression of client who is experiencing a crisis. E. correct. benzodiazepines may be prescribed to decrease the anxiety of a client who is experiencing a crisis

A nurse working in a n emergency department is caring for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority? A. administer flumazenil. B. identify the client's level of orientation. C. infuse IV fluids D. prepare the client for gastric lavage.

B. correct. When taking the nursing process approach to client care, the initial step is assessment. Identifying the client's level of orientation is the priority action.

A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply) A. age older than 65 years B. anxiety disorder C. childhood trauma D. coronary artery disease E. obesity

B. correct. anxiety disorder is a risk factor for somatic symptom disorder C. correct. childhood trauma is a risk factor for somatic symptom disorder

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (select all that apply) A. lethargy B. defensive responses to questions C. disorientation D. facial grimacing E. agitation

B. correct. defensive responses to questions are an assessment finding that can indicate that a client is in the preassaultive stage of violence D. correct. facial grimacing is an assessment finding that can indicate that a client is in the preassaultive stage of violence E. correct. agitation is an assessment finding that can indicate that a client is in the preassaultive stage of violence

A nurse is assessing a client who is currently taking perphenzaine. Which of the following findings should the nurse identify as an extrapyramidal symptom? (Select all that apply) A. decreased level of consciousness B. drooling C. involuntary arm movements D. urinary retention E. continual pacing

B. correct. drooling in an indication of pseudoparkinsonism, which is an EPS C. correct. involuntary arm movements are an indication of tardive dyskinesia, which is an EPS. E. correct. continual pacing is an indication of akathisia, which is an EPS

A nurse is teaching a child who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (select all that apply) A. An adverse effect of this medication is CNS depression B. administer the medication in the morning. C. monitor for weight loss while taking this medication D. therapeutic effects of this medication will take 1 to 3 weeks to fully develop E. this medication blocks the synaptic reuptake of serotonin in the brain

B. correct. fluoxetine should be administered in the morning due to the potential for insomnia C. correct. fluoxetine can result in weight loss. E. correct. fluoxetine works by blocking the synaptic reuptake of serotonin, allowing more serotonin to stay at the junction of the neurons

A nurse is caring for a client who is taking phenelzine. For which of the following manifestations should the nurse monitor as an adverse effect of this medication? (Select all that apply) A. elevated blood glucose level B. orthostatic hypotension C. priapism D. hypomania E. bruxism

B. correct. observe for orthostatic hypotension which is an adverse effect of phenelzine. D. correct. observe for a headache which is an adverse effect of phenelzine.

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling. B. Request that other staff members remain close by. C. Move as close to the client as possible D. Walk away from the client.

B. correct. request that other staff members remain close by to assist if necessary

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following findings are expected for this disorder? Select all that apply. A. Fear of being alone B. substance use C. weight gain D. irritability E. aggressiveness

B. correct. substance use is an expected finding associated with depression D. Correct. Irritability is an expected finding associated with depression E. Correct. Aggressiveness is an expected finding associated with depression

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? A. Clients educational and economic background B. lethality of the method and availability of means C. quality of the clients social support D. clients insight into the reasons for the decision

B. correct. the greatest risk to the client is self harm as a result of carrying out the suicide plan. The priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (select all that apply) A. somnolence B. yellowing skin C. increased appetite D. fever E. malaise

B. correct. yellowing skin is a potential indication of hepatotoxicity that the client should report to the provider D. correct. fever is a potential indication of hepatotoxicity that the client should report to the provider E. correct. malaise is a potential indication of hepatotoxicity that the client should report to the provider

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? A. response prevention B. guided imagery C. aversion therapy D. light therapy

B. guided imagery Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder.

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? A. polyphagia B. hypertension C. decreased temperature D. depressed mood

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

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? A. Obsessive attention to detail B. Inability to sleep C. reports of fatigueterm-69 D. isolation from others

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

A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make? A. "Clients can't refuse to take medications if they are admitted involuntarily." B. "You can notify a client's family if they are admitted involuntarily." C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." D. "You can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions."

C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures.

A nurse is providing teaching to the partner of a client who is in a 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? A. "I will avoid social events until my partner has completed treatment." B. "It is important for me to focus my attention on my partner's addiction." C. "I will not take charge of my partner's work responsibilities." D. "I want my partner to promise to change addictive behaviors."

C. "I will not take charge of my partner's work responsibilities." The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use the same plan of care and interventions for each client who has depression." B. "Each nurse will develop a separate plan of care for each client who has depression." C. "I will update the plan of care as a client's manifestations of depression change." D. "An assistive personnel can use the plan of care for client teaching."

C. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change.

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? A. "Why do you think you deserve this punishment? "B. "Don't worry about being punished by God." C. "Let's talk about what is upsetting you." D. "You shouldn't say things that will upset you so much."

C. "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 four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? A. A 17-year-old client who lives with friends B. A 50-year-old client who has a blood alcohol level of 80 mg/dL C. A 35-year-old client who has major depressive disorder D. A 65-year-old client who just received a dose of morphine

C. 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. A client refuses electroconvulsive therapy after signing the consent form. B. A client who was voluntarily admitted left the unit against medical advice. C. A client was administered one-half of the prescribed dose of medication. D. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.

C. A client was administered one-half of the prescribed dose of medication. An incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form.

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? A. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. B. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. C. A client who has borderline personality disorder threatened to harm their roommate. D. An adolescent client who has anorexia nervosa has a BMI of 17.

C. A client who has borderline personality disorder threatened to harm their roommate. Manifestations of borderline personality disorder include disturbed interpersonal relationships accompanied by threats and other-directed violence. While it is important for the nurse to maintain the client's confidentiality, on occasions when another individual's life might be in danger, the nurse is required by law to report it to authorities.

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? A. Complete documentation about the client's status every hour while they are in restraints. B. Maintain the client in restraints for a minimum of 4 hr. C. Apply restraints when other means of managing the client's behavior have failed. D. Request that the provider assess the client within 8 hr of the application of restraints.

C. Apply restraints when other means of managing the client's behavior have failed. According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.

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? A. Call the family member to the side to inquire if they have questions or concerns about the treatment plan. B. Advise the family member that this treatment plan has been developed specifically for the client to follow. C. Ask the family member if they have any thoughts or questions about the treatment plan. D. Document that the family member does not support the medication treatment plan

C. Ask the family member if they have any thoughts or questions about the treatment plan. This action involves the family member and allows them a venue to communicate about the client's medication 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 the nurse take? A. Ask the client to identify the bomb in the room. B. Initiate disaster protocols per facility policies and procedures. C. Assess the client for evidence of a perceptual disturbance. D. Convince the client that there is no bomb in their room.

C. 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 on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who has was hit for injuries.

C. Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A nurse is assisting the guardians of a school age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend? (Select all that apply) A. Allow the child to choose which behaviors are unacceptable B. Use role playing to act out unacceptable behavior C. Develop a reward system for acceptable behavior D. encourage the child to participate in school sports E. be consistent when addressing unacceptable behavior

C. Correct. The guardians should have a method to reward the child for acceptable behavior. D. Correct. The guardians should encourage physical activity through which the child can use energy and obtain success. E. correct. The guardians should set clear limits on unacceptable behavior and should be consistent

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 a temperature of 39.9° C (103.8° F). Which of the following actions should the nurse take first? A. Administer phentolamine 5 mg IV to the client. B. Apply a hypothermic blanket to the client. C. Determine the client's prescribed medication regimen. D. Initiate IV access for the client.

C. 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 in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A. Repeatedly talks about the traumatic incident B. Sleeps excessively C. Experiences feelings of isolation D. Uses repetitive speech

C. Experiences feelings of isolation The nurse should expect clients who have PTSD to feel estranged and detached from others.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? A. Raise the pitch of voice when speaking to a client B. Begin the interview by explaining the plan of care C. Interview the client in a private setting D. Ask the client to complete a detailed questionnaire

C. Interview the client in a private setting The nurse should interview clients in a private place when asking questions regarding client health.

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to participate in group therapy. B. Instruct the client to avoid napping during the day. C. Offer the client high-calorie finger foods frequently. D. Decrease the client's daily fiber intake.

C. Offer the client high-calorie finger foods frequently. The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration.

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A. An adolescent family member who questions parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household

C. Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.

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? A. Offer the client various choices for meal selection. B. Assign different nursing personnel for each shift. C. Permit the client to perform daily rituals to decrease anxiety. D. Maintain an environment that has low lighting.

C. Permit the client to perform daily rituals to decrease anxiety. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. report of a minimum of 5 clinical findings of depression C. presence of manifestations for at least 2 years D. inflated sense of self esteem

C. Presence of manifestations for at least 2 years. Manifestations of persistent depressive disorder last for at least 2 years in adults.

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? A. Schedule the client for group therapy sessions. B. Maintain consistent rules. C. Provide frequent high-calorie snacks. D. Avoid the use of value judgments.

C. 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? A. Controls anger outbursts to avoid being placed in seclusion B. No longer exhibits a fear of social or public situations C. Refrains from manipulating others to earn dining room privileges D. Imitates the therapist's use of a relaxation technique

C. Refrains from manipulating others to earn dining room privileges The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? A. Document the client's behavior every 8 hr. B. Limit the client's fluid intake to 50 mL/hr. C. Renew the prescription for the client every 4 hr. D. Toilet the client every 4 hr.

C. Renew the prescription for the client every 4 hr. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take? A. Assist the client to identify personal areas of strength. B. Encourage the client to talk about experiences during the deployment. C. Stay with the client when flashbacks occur. D. Teach the client stress-management techniques.

C. Stay with the client when flashbacks occur. The greatest risk to this client is injury that can occur during a flashback; therefore, the priority intervention for the nurse is to remain with the client and offer reassurance and support when flashbacks occur.

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? A. Encourage the parents to avoid discussing the death with their other children to protect their feelings. B. Recommend each parent grieve in private to avoid hindering each other's healing. C. Suggest forming a weekly support group for parents who have experienced the death of a child. D. Advise the parents to begin counseling if they are still grieving in a few months.

C. Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child.

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? A. The client is married. B. The client recently received a promotion at work. C. The client has COPD. D. The client is a male.

C. The client has COPD. The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.

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? A. The client will take prescribed medications as scheduled. B. The client will express feelings of frustration. C. The client will refrain from self-mutilation. D. The client will participate in group therapy.

C. 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 nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? A. delusions B. neologisms C. anhedonia D. echopraxia

C. anhedonia Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

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? A. offering self B. use of silence C. attention to body language D. reflection of feelings

C. 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 assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long-term abstinence from alcohol? (select all that apply) A. lorazepam B. diazepam C. disulfram D. naltrexone E. acamprosate

C. correct. Disulfram promotes abstinence through aversion therapy D. correct. Naltrexone promotes abstinence by suppressing the craving and pleasurable effects of alcohol E. correct. Acamprosate decreases the unpleasant effects resulting from abstinence

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse include in the teaching? A. chew the gum for no more than 10 mins B. rinse out the mouth immediately before chewing the gum C. avoid eating 15 mins prior to chewing the gum D. use of the gum is limited to 90 days

C. correct. The client should avoid eating or drinking 15 mins prior to and while chewing the gum

A nurse is caring for a client who was recently sexually assaulted. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do you feel that you should not have been alone on the street at night?"

C. correct. This response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings.

A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet while taking this medication." C. I will need to discontinue this medication slowly." D. I will be at risk for weight loss with long term use of this medication."

C. correct. When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal syndrome.

A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another? A. "I had to pretend I was injured in order to get disability benefits." B. "Monitor the client for self-harm once per day." C. "Allow the client unlimited time to discuss physical manifestations." D. "Discuss alternative coping strategies with the client."

C. correct. a client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility.

A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicate understanding of the teaching? A. "I will be able to to stop taking this medications as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication.' D. "This medication is highly addictive and must be withdrawn slowly."

C. correct. antipsychotic medications have a high risk for significant weight gain.

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following medications? A. Chlorpromazine B. Thiothixene C. Risperidone D. Haloperidol

C. correct. second generation antipsychotics are effective in treating negative symptoms of schizophrenia.

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the dayroom. Which of the following is the priority nursing action? A. encourage the client to express feelings out loud B. maintain eye contact with the client C. move the client away from others D. tell the client that the behavior is not acceptable

C. correct. the behavior indicates that the client is at greatest risk for harming others. The priority action for the nurse is to move the client away from others.

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression. B. The client currently smokes 1.5 packs of cigarettes per day. C. The client had a motor vehicle crash last year and sustained a head injury. D. The client has a BMI of 25 and has gained 10 lbs over the last year.

C. correct. the greatest risk to the client is development of seizures. Buproprion can lower the seizure threshold and should be avoided by clients who have a history of head injury. This information is the highest priority to report to the provider.

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? A. reduced appetite B. fatigue C. dark urine D. sweating

C. 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 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? A. calling family members B. spending time alone C. giving away possessions D. excessive crying

C. 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 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? A. sore throat B. photophobia C. hand tremors D. constipation

C. hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication.

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? A. male gender B. hyperthyroidism C. substance use disorder D. being married

C. substance use disorder The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? A. weight gain B. tinnitus C. tachycardia D. increased salivation

C. tachycardia The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

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? 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."

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

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? A. "I wish I had been nicer and more generous with 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."

D. "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 charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? A. "Information regarding clients should remain confidential until after their death." B. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." C. "As long as client identity is disguised, their health information can be shared between professionals on the internet." D. "In the event a client threatens harm to others, medications can be administered without consent."

D. "In the event a client threatens harm to others, medications can be administered without consent. "The charge nurse should inform the participants that their primary commitment is to the client and their priority is always to advocate for and protect their health and safety. During an emergency situation, if the client is threatening harm to self or others, medications can be administered without the client's consent and without a court order.

A nurse is caring for a 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? A. "It will be better for you to keep busy to avoid thinking about your child's death." B. "You will complete the grieving process about a year after your child's death." C. "The grief process will start once your child actually dies." D. "It is not uncommon to feel angry toward yourself or others."

D. "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 on 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. A client who does not recognize familiar people B. A client who cannot verbalize their needs C. A client who is awake and disoriented at night D. A client who is experiencing delusions of persecution

D. 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 them. Therefore, the nurse should assess this client first.

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse plan to see first? A. A client who has avoidant personality disorder and refuses to attend group therapy B. A client who has bipolar disorder and reports being kidnapped by aliens overnight C. A client who is taking bupropion and reports having insomnia the past 2 nights D. A client who is taking clozapine and reports a sore throat and chills

D. A client who is taking clozapine and reports a sore throat and chills When using the urgent vs. nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect that causes neutropenia. The nurse should withhold the medication and notify the provider of these findings.

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? A. Blurred vision B. Orthostatic hypotension C. Dry mouth D. Acute dystonia

D. 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? A. Feelings of remorse B. Extended periods of depression C. Deficits in intellectual functioning D. Aggression toward animals

D. 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 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? A. Tell the client that the voices do not really exist. B. Touch the client to help reduce feelings of anxiety. C. Instruct the client to go to a quiet room when the voices start talking. D. Ask the client what the voices are saying.

D. 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 nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdiscplinary services for the client at home? A. Community mental health center B. Mental health day program C. Partial hospitalization program D. Assertive community treatment

D. Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

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? A. Ensure a family member can be present during treatment. B. Increase fluid intake for 24 hr before the treatment starts. C. Change position slowly when the treatment is complete. D. Avoid looking directly at the light during treatment.

D. Avoid looking directly at the light during treatment. Light therapy, or phototherapy, can cause sensitivity to light. To minimize this effect, the client should avoid looking directly at the light.

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? A. Obtain the weight of a client who has bipolar disorder and is experiencing mania. B. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. C. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. D. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

D. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound.

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others? A. Inability to communicate with others B. Feelings of absence of self-worth C. Lack of motivation to perform daily tasks D. Command hallucinations

D. Command hallucinations A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted

D. Easily distracted Extreme distractibility is a hallmark manifestation of delirium.

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 manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? A. Inability to recognize family members B. Chooses clothing that is inappropriate for the weather C. Exhibits a change in personality D. Frequently misplaces objects

D. Frequently misplaces objects According to evidence-based practice, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur.

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)? A. Clinging behaviors directed toward a teacher B. Increased time spent sleeping C. Intense focus on school work D. Lack of interest in an upcoming holiday

D. 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? A. Fear of abandonment B. Motor and verbal tics C. Hostile behavior D. Language delay

D. Language delay The nurse should identify that language delays are a manifestation of autism spectrum disorder.

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? A. Panic B. Moderate C. Severe D. Mild

D. Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? A. Administer phenytoin 30 min prior to the procedure. B. Instruct the client to expect a headache following the procedure. C. Place the client in four point restraints prior to the procedure. D. Monitor the client's cardiac rhythm during the procedure.

D. Monitor the client's cardiac rhythm during the procedure. The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram.

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A. Lansoprazole B. Naproxen C. Magnesium Hydroxide D. Phenylephrine

D. Phenylephrine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? A. Encourage expression of feelings. B. Support the child's attendance at an assertiveness training group. C. Assist the child to perform relaxation breathing. D. Reduce environmental stimuli.

D. Reduce environmental stimuli. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

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? A. Decrease distractions during meal times. B. Provide positive feedback when the child completes a task. C. Clearly identify consequences for unacceptable behavior. D. Remove unnecessary equipment from the child's surroundings.

D. Remove unnecessary equipment from the child's surroundings. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to 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? A. Confront the staff member. B. Encourage the client to report the incident. C. Document the incident in the client's health record. D. Report the occurrence to the charge nurse.

D. Report the occurrence to the charge nurse. It is the charge nurse and the nurse manager's responsibility to confront the staff member about the derogatory comments made to the client.

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? A. Allowing a client to choose which unit activities to attend B. Attempting alternative therapies instead of restraints for a client who is combative C. Providing a client with accurate information about their prognosis D. Spending adequate time with a client who is verbally abusive

D. Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care.

A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Discuss outpatient resources with a client who has post-traumatic stress disorder. B. Create a plan of care for a client who is experiencing alcohol withdrawal. C. Explain sleep hygiene to a client who has insomnia. D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes.

D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes. Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and this task does not require assessment or technical skill.

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? A. Move the client to a room near the nurses' station. B. Limit visitors until the client is oriented to the environment. C. Tell the client that their partner is deceased. D. Talk with the client about activities they enjoyed with their partner.

D. Talk with the client about activities they enjoyed with their partner. Talking about positive experiences can help distract the client from their disorientation.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? A. Amenorrhea B. Lanugo C. Cold extremities D. Tooth erosion

D. Tooth erosion A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry." B. "I feel angry when you leave me." C. It makes me angry when you interrupt me." D. You'd better listen to me."

D. correct. This statement implies a threat and a lack of respect for another individual

A nurse is teaching a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse provide? A. three to six weeks of treatment is required to achieve therapeutic benefit. B. combining alcohol with alprazolam will produce a paradoxical response. C. alprazolam has a lower risk for dependence than other antianxiety medications. D. report confusion as a potential indication of toxicity.

D. correct. confusion is a potential indication of alprazolam toxicity that the client should report to the provider

A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. encourage the client to spend time alone in their room. B. monitor the client for self-harm once per day C. allow the client unlimited time to discuss physical manifestations D. discuss alternative coping strategies with the client.

D. correct. discuss alternative coping strategies with the client.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is the priority to report to the provider? A. "Current medical conditions include diabetes that is controlled by diet." B. "Recent medications include a course of prednisone for acute bronchitis." C. "Current vaccinations include a flu vaccine last month." D. "Current medications include furosemide for congestive heart failure.

D. correct. diuretics are contraindicated for use with lithium due to the risk for toxicity. This is the greatest risk for client and is therefore the highest priority to report to the provider.

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (select all that apply) A. genitourinary soreness B. difficulties with low self esteem C. sleep disturbances D. emotional outbursts E. difficulty making decisions

D. correct. emotional outbursts indicate an expressed initial reaction of rape-trauma syndrome E. correct. difficulty making decisions indicates a controlled initial reaction of rape-trauma syndrome.

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. Assign the client to a private room B. document the clients behavior every hour C. allow the client to keep perfume in her room D. ensure that the client swallows medication

D. correct. ensure that the client swallows medication to prevent hoarding of medication for an attempt to exceed they prescribed dose

A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A. apply the patch once daily at bedtime B. place the patch carefully in a trash can after removal C. apply the transdermal patch to the anterior waist area. D. remove patch each day after 9 hrs

D. correct. the transdermal patch is applied once daily in the morning and is removed after 9hrs

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat of suicide is attention seeking behavior B. interventions are ineffective for clients who really want to commit suicide C. using the term suicide increases the clients risk for suicide attempt D. A no suicide contract decreases the clients risk for suicide

D. correct. the use of a no suicide contract decreases the clients risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies

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? A. increased confusion B. sleep disturbances C. cluttered environment D. inappropriate dress

D. inappropriate dress Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? A. Diarrhea B. heavy menstrual bleeding C. tachycardia D. orthostatic hypotension

D. orthostatic hypotension Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 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.)

ollow these steps for the Desired Over Have method of calculation:Step 1: What is the unit of measurement the nurse should calculate? kgStep 2: Set up an equation and solve for X.Client's weight in lb × 1 kgX kg = 2.2 lb110 lb × 1 kgX kg = 2.2 lbX kg = 50 kgStep 3: What is the unit of measurement the nurse should calculate? mgStep 4: Set up an equation and solve for X.X = Dose per kg × Client's weight in kgX mg = 0.55 mg/kg × 50 kgX mg = 27.5 mgStep 5: What is the unit of measurement the nurse should calculate? mLStep 6: What is the dose the nurse should administer? Dose to administer = Desired 27.5 mgStep 7: What is the dose available? Dose available = Have 10 mgStep 8: Should the nurse convert the units of measurement? NoStep 9: What is the quantity of the dose available? 5 mLStep 10: Set up an equation and solve for X.Desired × QuantityX = Have27.5 mg × 5 mLX mL = 10 mgX mL = 13.75 mLStep 11: Round if necessary. 13.75 = 14 mLStep 12: Determine whether the amount to administer makes sense. If there are 10 mg/5 mL and the prescription reads 0.55 mg/kg, it makes sense to administer 14 mL. The nurse should administer chlorpromazine syrup 14 mL PO.