PN Mental Health Online Practice 2020 A with NGN

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for Chlorpromazine. Which of the following statements should the nurse include in the teaching? A. "The voices you have been hearing should decrease." B. "You will likely have more energy while on this medication." C. "You should now be able to spend more time in the sun." D. "Call your provider immediately if you develop a dry mouth."

A. "The voices you have been hearing should decrease." Rationale: The nurse should instruct the client that hallucinations and agitated behavior, which are positive symptoms of schizophrenia, are targeted by conventional antipsychotic agents, such as chlorpromazine. **B. Chlorpromazine causes sedation. Therefore, the client will not have more energy while taking this medication. Lack of energy is a negative symptom of schizophrenia and is not targeted by conventional antipsychotic medications, such as chlorpromazine. C. Photosensitivity is an adverse effect of chlorpromazine. The medication can increase sensitivity to sunlight, which can increase the risk for sunburn and can cause changes in skin pigmentation. The nurse should instruct the client to minimize time in the sun and to use sunscreen and protective clothing when outside. D. The nurse should reinforce teaching about what the client should do if they develop a dry mouth, such as rinsing their mouth frequently or chewing sugarless gum. Dry mouth is an anticholinergic effect, but it does not indicate a severe adverse effect and, therefore, does not require a call to the provider.

A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action appears on the television, the client says to the nurse, "My youngest child died 6 months ago while serving in the military." Which of the following responses should the nurse make? (Select all that apply.) A. "This must be a very difficult time for you." B. "Your child's death must be a terrible loss." C. "It's just awful what is going on in the world." D. "You need to focus on getting better." E. "Tell me something you remember about your child."

A. "This must be a very difficult time for you." B. "Your child's death must be a terrible loss." E. "Tell me something you remember about your child." Rationale: "This must be a very difficult time for you" is correct. This statement demonstrates the use of reflecting. Reflecting expresses the nurse's observations of the client's verbal and nonverbal behaviors when discussing sensitive issues. This therapeutic communication technique encourages clients to accept and embrace their own feelings."Your child's death must be a terrible loss" is correct. This statement demonstrates the use of reflecting. Reflecting expresses the nurse's observations of the client's verbal and nonverbal behaviors when discussing sensitive issues. This therapeutic communication technique encourages clients to accept and embrace their own feelings."It's just awful what is going on in the world" is incorrect. This statement demonstrates a nontherapeutic response because it changes the subject and diverts attention away from the client's grief. This belittles and invalidates the client's feelings."You need to focus on getting better" is incorrect. This statement demonstrates a nontherapeutic response because it negates the client's feelings and makes the assumption that the nurse knows best. This prevents problem solving and can cause the client to feel misunderstood, insignificant, and unsupported."Tell me something you remember about your child" is correct. This statement demonstrates the use of exploring. Exploring acknowledges the client's feelings and facilitates communication between the client and the nurse.

A nurse is reinforcing teaching with a newly admitted client who has generalized anxiety disorder. Which of the following statements should the nurse make? A. "We will demonstrate for you how to use relaxation techniques." B. "Someone will be here to work with you when you experience flashbacks." C. "Aversion therapy will be used to decrease your anxiety level." D. "Response prevention therapy will help you control your impulses."

A. "We will demonstrate for you how to use relaxation techniques." Rationale: The nurse should explain and demonstrate the use of relaxation techniques to decrease feelings of anxiety in clients who have generalized anxiety disorder. Examples of these techniques are progressive relaxation and deep breathing exercises. **B. Clients who have posttraumatic stress disorder, not generalized anxiety disorder, experience flashbacks, and, therefore, receive therapy that includes treatment for flashbacks. C. Aversion therapy is not used for the treatment of generalized anxiety disorders. D. Response prevention therapy is used to limit ritualistic acts for clients who have obsessive-compulsive disorder.

A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence? A. A nurse does not notify the provider of a change in condition for a client who has schizophrenia. B. A nurse delegates an assistive personnel to sit with a client who has bulimia nervosa during mealtimes. C. A nurse administers an anti-anxiety medication to a restless client who has given implied consent. D. A nurse does not document the completion of an incident report about a recent fall in the client's medical record.

A. A nurse does not notify the provider of a change in condition for a client who has schizophrenia. Rationale: Negligence is the failure to act in a manner which follows the standard of care. The nurse should inform the provider of any changes in a client's condition. Failure to do so is considered negligence. **B. The nurse should delegate tasks to an assistive personnel (AP) that are within the AP's permitted range of function. Sitting with a client who has bulimia nervosa during mealtime to prevent purging is an appropriate action for the nurse to delegate after ensuring the AP understands what to report to the nurse. This action is not an example of negligence. C. The nurse should administer prescribed medications to a restless client who has given implied consent for a routine task, such as medication administration. Implied consent is a nonverbal indication that the client agrees to the treatment plan. Receiving implied consent before administering medications is not an example of negligence. D. The nurse should document objective information about the incident in the client's medical record. Information regarding the completion of the incident report is not documented in the client's medical record. Incident, or occurrence, reports are used as part of a quality improvement program for the facility and are not placed in the medical record. Failing to document this information in a medical record is not an example of negligence.

A nurse is assisting with the admission of a client who has schizophrenia. Which of the following actions should the nurse take first? A. Conduct an abnormal involuntary movement scale test. B. Discuss behavioral expectations with the client. C. Orient the client to unit routines. D. Encourage the client to attend group art sessions.

A. Conduct an abnormal involuntary movement scale test. Rationale: The first action the nurse should take when using the nursing process is to collect data. The abnormal involuntary movement scale (AIMS) test is a data collection tool used to guide medication therapy for clients who are prescribed antipsychotic medications. Therefore, the first action the nurse should take is to conduct the AIMS test. **B. Discuss behavioral expectations with the client. Discussing behavioral expectations with the client is important to encourage expected behavior and to discourage undesirable behavior. However, there is another action that the nurse should take first. C. Orienting the client to unit routines is important to create a sense of security and promote a therapeutic environment. However, there is another action that the nurse should take first. D. Participation in art therapy, such as drawing or listening to music, can assist a client with recognition and expression of specific feelings. However, there is another action that the nurse should take first.

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

A. Establish and explain consequences for the client's behavior. Rationale: The nurse should communicate desired behavior and expectations as well as detailed consequences for not meeting those expectations to a client who has borderline personality disorder. These expectations and consequences should be included in the plan of care when addressing limit setting with the client.

A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following findings is an indicator of the client's use of this substance? A. Hypertension B. Drowsiness C. Bradycardia D. Constricted pupils

A. Hypertension Rationale: Cocaine is a central nervous system stimulant. Therefore, hypertension is an expected finding. **B. Mental alertness is an expected finding of cocaine use. C. Tachycardia is an expected finding of cocaine use. D. Dilated pupils are an expected finding of cocaine use.

A nurse is organizing care for a group of clients. According to Maslow's hierarchy of needs, which of the following interventions should the nurse plan to perform first? A. Offer finger foods to a client who is in the manic phase of bipolar disorder. B. Document the affect of a client who had light therapy for seasonal affective disorder 2 days ago. C. Assist a client who has a depressive disorder with decision making regarding group activities. D. Reinforce teaching about a new prescription of clozapine with a client who has schizophrenia.

A. Offer finger foods to a client who is in the manic phase of bipolar disorder. Rationale: When using Maslow's hierarchy of needs, the nurse should determine that the priority action is to address a client's physiological needs. By offering finger foods, the nurse allows the client to eat while in motion, which helps to meet the client's daily calorie requirements. **B. It is important to document and evaluate the affect of a client who has seasonal affective disorder to determine the effectiveness of the treatment. However, it is not the first action the nurse should take. C. Assisting a client who has a depressive disorder with decision making regarding group activities is important to promote the client's autonomy. However, it is not the first action the nurse should take. D. Reinforcing teaching about medications with a client who has schizophrenia is important to promote the client's self-management and adherence to the treatment plan. However, it is not the first action the nurse should take.

A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few moments later, the client cheerfully states, "Now, here is my favorite social worker!" The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Dissociation C. Denial D. Projection

A. Reaction formation Rationale: The nurse should identify that this client is using reaction formation. This is the defense mechanism in which the client is unable to process unacceptable feelings or behaviors and expresses the opposite to decrease anxiety. **B. Dissociation is the defense mechanism in which unpleasant or anxiety-producing memories or experiences are separated from the client's awareness to decrease anxiety. C. Denial is the defense mechanism in which the client ignores unpleasant or anxiety-producing events to decrease anxiety. D. Projection is the defense mechanism in which the client has feelings or behaviors that are personally unacceptable. As a result, the client attributes these feelings to others to decrease anxiety.

A nurse is caring for a client who has bipolar and is experiencing a manic episode. Which of the following interventions should the nurse take first? A. Remove harmful objects from the client's room. B. Decrease the client's environmental stimuli. C. Administer an antipsychotic medication to the client. D. Provide physical activities for the client.

A. Remove harmful objects from the client's room. Rationale: The greatest risk to this client is self-injury or injury to others. Therefore, the first action the nurse should take is to remove harmful objects from the client's room to protect the client. **B. The nurse should decrease the environmental stimuli to assist with decreasing manifestations of mania. However, there is another action that the nurse should take first. C. The nurse might need to administer an antipsychotic medication to decrease manifestations of mania. However, there is another action that the nurse should take first. D. The nurse should provide an opportunity for the client to participate in physical activities to relieve tension. However, there is another action that the nurse should take first.

A nurse is assisting with discharge planning for a client who needs to attend a day treatment center and has limited community and financial support. Which of the following referrals should the nurse recommend including in the client's discharge plan? A. Social worker B. Recreational therapist C. Psychologist D. Pharmacist

A. Social worker Rationale: Social workers can assist clients with building a support structure to help promote and preserve mental health, including contacting day treatment centers and arranging for financial and other community resources. **B. Although recreational therapists can promote therapies, such as art and music, to help enhance and preserve mental health, they do not usually address issues regarding financial support and community resources. C. Although psychologists can provide individual or family therapy for clients, they do not usually address issues regarding financial support and community resources. D. Pharmacists prepare prescribed medications and dispense medications in acute care and community settings. They coordinate with the provider and nurses regarding the client's medication regime. However, they do not address issues regarding financial support and community resources.

A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? A. "For the first step of my therapy, I will look at pictures of cars." B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car." C. "My therapist will be with me while we ride in a car together." D. "I will ride in a car for several hours at a time."

B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car." Rationale: This statement describes thought stopping, which is used to interrupt a client's negative thought with a distraction. **A. This statement describes systematic desensitization, not thought stopping. C. This statement describes modeling, not thought stopping. D. This statement describes flooding, not thought stopping.

A nurse is caring for a client who recently experienced a traumatic event. EXHIBIT 1: Vital Signs 0730 Temperature 36.6° C (97.9° F) Pulse rate 74/min Respiratory rate 16/min Blood pressure 118/74 mm Hg 1530 Temperature 36.9° C (98.4° F) Pulse rate 86/min Respiratory rate 18/min Blood pressure 114/78 mm Hg EXHIBIT 2: Nurses' Notes 0730 Admit note: Client was a bystander during a recent violent crime at their place of employment. Several of the client's friends and coworkers were killed. The client has been experiencing feelings of guilt and anger. 1700 The client continues to express feelings of guilt and anger and states, "I cannot ever go back to work. It is too dangerous." The client also states, "I don't know why I was allowed to survive. It's too painful to speak to my friends and family about what happened." A nurse is reinforcing teaching to the client. Which of the following statements should the nurse include? Select all that apply. A. "It is uncommon for people who survived a traumatic event to experience spiritual distress." B. "It is common for people who survived a traumatic event to experience feelings of anxiety." C. "A support group can help you during this time.

B. "It is common for people who survived a traumatic event to experience feelings of anxiety." C. "A support group can help you during this time." E. "You should seek help if you have thoughts of self-harm." Rationale: "It is uncommon for people who survived a traumatic event to experience spiritual distress" is incorrect. Clients who have experienced a traumatic event often experience spiritual distress as a result. "It is common for people who survived a traumatic event to experience feelings of anxiety" is correct. Clients who have experienced a traumatic event might demonstrate manifestations of severe anxiety and panic attacks, including impulsivity and regression. "A support group can help you during this time" is correct. The nurse should encourage the client to attend a support group, because support groups can provide emotional support for clients who have experienced a traumatic event. "You will have minimal problems performing your daily self-care tasks" is incorrect. Clients who have experienced a crisis can have difficulty meeting their basic needs and performing self-care tasks. The nurse might need to assist the client to perform ADLs. "You should seek help if you have thoughts of self-harm" is correct. The nurse should inform the client that they should seek help immediately if they experience thoughts of self-harm, suicidal ideation, or homicidal ideation.

A nurse is caring for a client who has anxiety disorder and is refusing to take a medication. Which of the following responses should the nurse make? A. "This medication is safe for you to take." B. "You have the right to refuse this medication." C. "You are presenting a risk to the other clients." D. "This medication is part of your treatment plan."

B. "You have the right to refuse this medication." Rationale: Clients have the right to refuse treatment, including medications, unless the client undergoes a court hearing and the judge decides that the client meets the criteria for involuntary medication administration.

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect? A. Amenorrhea B. Dental caries C. Lanugo D. Yellow skin

B. Dental caries Rationale: The nurse should expect manifestations of bulimia nervosa to include dental caries, which can lead to tooth erosion. Dental caries are caused by the increased acid in the stomach that is found in the vomitus of clients who purge repeatedly. **Amenorrhea is a manifestation of anorexia nervosa that is caused by a fluid and electrolyte imbalance. Lanugo is a manifestation of anorexia nervosa that is caused by starvation. Yellow skin is a manifestation of anorexia nervosa that is caused by carotenemia.

A nurse is caring for an adult client who has visible injuries as a result of partner violence. Which of the following actions should the nurse take? A. Insist that the client report the incident to the authorities before beginning treatment. B. Encourage the client to develop a safety plan. C. Recommend that the partner remain in the room during the interview with the client. D. Advise the client to obtain an order of protection from the court.

B. Encourage the client to develop a safety plan. Rationale: The nurse should encourage the client to develop a safety plan to aid in escaping further violence if necessary. **A. Client safety, including treatment for the client's injuries, should be the nurse's priority. The nurse should support the client's decision to seek treatment, and the nurse should ask the client if they need assistance with making a report. However, it is the client's choice whether or not to report the incident to authorities. Members of the health care team might be required to report partner violence themselves if the client has been assaulted by a weapon or if rape has occurred, depending on individual state laws. C. The nurse should interview the client privately without the partner present. D. Giving advice is not a therapeutic technique. The nurse should offer support for the client's own decisions and refrain from offering advice.

A nurse is monitoring the nutritional status of a client who has bulimia nervosa. The nurse should monitor the client for which of the following complications? A. Hyperchloremia B. Hyponatremia C. Decreased bone density D. Increased WBC count

B. Hyponatremia Rationale: The nurse should monitor clients who have bulimia nervosa for hyponatremia, which results from purging, vomiting, and laxative and/or diuretic use. **A. The nurse should monitor clients who have bulimia nervosa for hypochloremia, not hyperchloremia. C. Decreased bone density is a potential complication of anorexia nervosa, not bulimia nervosa. D. An increased WBC count is an indication of infection. However, this is not an expected complication of bulimia nervosa.

A nurse in a mental health facility is caring for a client who is becoming agitated. Which of the following actions should the nurse take first? A. Place the client in seclusion. B. Offer diversionary activities. C. Administer haloperidol. D. Apply wrist restraints.

B. Offer diversionary activities. Rationale: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should offer diversionary activities to distract the client and redirect their energy into more appropriate behaviors. **A. The nurse might need to place the client in seclusion to decrease noise and environmental stimuli in order to assist with de-escalating the client's agitation. However, there is another less restrictive intervention that the nurse should implement first. C. The nurse might need to administer haloperidol to assist with de-escalating the client's agitation. However, there is another less restrictive intervention that the nurse should implement first. D. The nurse might need to apply wrist restraints to decrease the client's risk for injury or to prevent harm to others. However, there is another less restrictive intervention that the nurse should implement first.

A nurse is collecting data from a client who has bipolar disorder and a history of mania. Which of the following findings should the nurse identify as an indication that the client is relapsing? A. Weight gain B. Pressured speech C. Ritualistic behavior D. Anhedonia

B. Pressured speech Rationale: The nurse should identify that rapid or pressured speech, provocative behavior, and insomnia are indications of potential relapse in a client who has bipolar disorder and a history of mania.

A nurse n a provider's office is collecting data from an older adult client whose adult child reports that the client "seems confused and can't seem to remember much." Which of the following findings should lead the nurse to suspect delirium? A. The client's confusion worsens during times of stress. B. The client's level of consciousness changes during the interview. C. The client's confusion improves in the evening. D. The client has a flat affect during the interview.

B. The client's level of consciousness changes during the interview. Rationale: Delirium can rapidly alter the client's level of consciousness, which can manifest as agitation or stupor. Therefore, the nurse should suspect that this client is experiencing delirium. **A. A client who has depression would exhibit an exacerbation of confusion during times of stress. C. The client's confusion will worsen in the evening, and the sleep-wake cycle might be reversed. D. A client who has depression would exhibit a flat affect and be slow to respond when speaking.

A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client's confidentiality? A. The nurse documents subjective data about the client's condition in the client's medical record. B. The nurse places the client's diagnosis on the whiteboard in the client's room. C. The nurse faxes the client's allergies to the pharmacy. D. The nurse reports threats that the client made to harm their partner to the provider.

B. The nurse places the client's diagnosis on the whiteboard in the client's room. Rationale: Writing information about the client's diagnosis or medical condition on the whiteboard in the client's room is a violation of HIPAA. However, message boards in the client's room can be used to post nursing care information. **A. The nurse should document accurate data in the client's medical record so that other health care team members providing direct care to the client are able to plan additional care. C. The nurse can fax the client's allergies to the pharmacy and should share client information with health care personnel who are directly involved in the care of the client. D. The nurse is required to report threats made by the client about harming others to the provider. This is not considered a breach of confidentiality because it is part of the duty to warn.

A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statements should the nurse make to gather information about the client's ability to think abstractly? A. "Subtract 7 from 100 and then continue subtracting 7 from each answer." B. "What do you think about when you are angry?" C. "How is an orange similar to an apple?" D. "Tell me about a vacation you took when you were a child."

C. "How is an orange similar to an apple?"' Rationale: Asking the client to explain similarities between objects or to explain the meaning of a common proverb or figure-of-speech tests the client's ability to think abstractly. **A. The process of "serial sevens" tests the client's ability to attend to a task. B. Asking the client to talk about personal thoughts provides information about the client's feelings, emotions, and behaviors. D. Asking the client about something that happened in childhood tests the client's remote memory.

A nurse is caring for a client who gave birth to a stillborn fetus 1 week ago. The client states to the nurse, "I am so angry that my doctor didn't take better care of me and my baby." Which of the following responses should the nurse make? A. "You should concentrate on feeling better. You've been through a lot." B. "You should begin to accept what happened, so you can work through your loss." C. "It is important to share what you are feeling, even if it is anger." D. "Everyone experiences anger at first. This will pass over time."

C. "It is important to share what you are feeling, even if it is anger." Rationale: The nurse is encouraging the client to discuss their perception of the loss, which is a therapeutic communication technique. It is helpful to acknowledge that anger is an expected reaction to loss and encourage the client to verbalize their feelings. **A. The nurse is changing the subject and minimizing the client's feelings, which is a nontherapeutic communication technique and belittles the client's grief. B. The nurse is giving advice with this response, which is a nontherapeutic technique that implies the nurse knows what is best for the client. This type of response can cause the client to feel as though their feelings are not important to the nurse, which discourages the client from any further disclosure of emotions. D. The nurse is minimizing the feelings of the client, which is a nontherapeutic communication technique that does not provide support to the client.

A nurse is assisting with screening a group of clients for a major depressive disorder (MDD). The nurse should identify that which of the following clients is at an increased risk for the development of MDD? A. A client who is newly employed B. A client who abstains from alcohol C. A client who just gave birth D. A client who has been married for 15 years

C. A client who just gave birth Rationale: Clients who just gave birth or are in the early postpartum period are at an increased risk for developing MDD or postpartum depression. **A. There is a relationship between socioeconomic class and depression. However, it is not proven that employment status has an effect on the development of MDD. B. Clients who have alcohol or substance use disorders are at an increased risk for developing MDD. D. Clients who are married are at a decreased risk for developing MDD. Marriage or close relationships have been shown to have a calming effect on the well-being of an individual's psychological status when compared to those who are single or who lack a close relationship with another person.

A nurse observes a client who has schizophrenia and exhibits akathisia. Which of the following interventions should the nurse implement? A. Provide a handkerchief to the client to wipe excess saliva. B. Initiate seizure precautions. C. Administer an antiparkinsonian agent. D. Implement emergency cooling measures.

C. Administer an antiparkinsonian agent. Rationale: The nurse should anticipate that an antiparkinsonian agent will be administered for akathisia, which is an adverse effect of an antipsychotic medication for the treatment of schizophrenia. **A. The nurse should provide a handkerchief to a client who has pseudoparkinsonism, not akathisia. B. This manifestation does not place the client at risk for seizures. D. The nurse should implement cooling measures for a client who has anticholinergic toxicity, not akathisia.

A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia? A. Delusions B. Echolalia C. Apathy D. Paranoia

C. Apathy Rationale: Negative symptoms of schizophrenia are deficits in the client's ability to experience emotions. Apathy is a negative symptom of schizophrenia that is manifested by a loss of interest in one's surroundings. **A. Positive symptoms of schizophrenia are distortions of mental health functions. False beliefs, such as delusions, are a type of positive symptom of schizophrenia. B. Echolalia, the repetition of words spoken by someone else, is a positive symptom of schizophrenia. Clients who have schizophrenia often display alterations in speech, such as echolalia. D. Paranoia is an unfounded fear of others and is a positive symptom of schizophrenia.

A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? A. Call for assistance to place the client in restraints. B. Administer a sedative to the client. C. Determine the client's intentions. D. Place the client into the assigned seclusion room.

C. Determine the client's intentions. Rationale: The first action the nurse should take when using the nursing process is to collect data from the client. By determining the client's intentions, the nurse can de-escalate the situation by talking to the client in a calm manner. This intervention will assist the nurse in establishing a trusting relationship with the client. **A. The nurse should identify that the client might need to be placed in restraints if all other means of de-escalation are ineffective. However, there is another action that is the priority. B. The nurse should identify that the client might need medication to decrease aggression and anxiety if other means of de-escalation are ineffective. However, there is another action that is the priority. D. The nurse should identify that the client might need to be placed into the assigned seclusion room and monitored one-on-one to prevent self-endangerment if other actions are ineffective. However, there is another action that is the priority.

A nurse is reinforcing teaching with a client whose provider has prescribed electroconvulsive therapy (ECT). Which of the following information should the nurse include? A. The client will receive continuous oxygen during the electrical stimulation intervals. B. A benzodiazepine will be administered prior to the procedure. C. ECT is an option for clients after medication has been unsuccessful. D. Confusion is expected for the first 2 days after treatment.

C. ECT is an option for clients after medication has been unsuccessful. Rationale: Medication is the first-line of treatment for depression. ECT is prescribed when medication has been unsuccessful. **A. The client will receive oxygen throughout the procedure. However, the oxygen will be removed during the brief electrical stimulation intervals. B. A benzodiazepine should not be administered because it interferes with the seizure process. A short-acting anesthetic, such as propofol, will be administered. D. Clients who receive ECT can have confusion and disorientation for several hours after treatment.

A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? A. Inability to make decisions B. Anhedonia C. Feelings of hopelessness D. Fatiuge

C. Feelings of hopelessness Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should identify that feelings of hopelessness indicate that this client is at risk for suicide. Therefore, this is the priority finding for the nurse to report to the provider. **A. The inability to make decisions affects the client's concentration, which decreases the client's ability to complete tasks. However, another finding is the priority to report. B. Anhedonia is the lack of pleasure or interest in activities or the lack of the capacity to experience pleasure. However, another finding is the priority to report. D. Fatigue indicates that the client is at risk for inability to complete ADLs. However, another finding is the priority to report.

A nurse is contributing to the plan of care for a client who has bipolar disorder. Which of the following actions should the nurse include to promote a therapeutic environment during the working phase of the nurse-client relationship? A. Establish rapport B. Explain confidentiality and privacy C. Reinforce teaching about medication D. Specify a contract

C. Reinforce teaching about medication Rationale: Reinforcing teaching about medication is an essential component of the working phase of the nurse-client relationship that the nurse should perform. The knowledge about the client's prescribed medications prepares the client to take an active role in their care. **A. Establishing rapport is a task the nurse should perform during the orientation phase of the nurse-client relationship. B. Explaining confidentiality is a task the nurse should perform during the orientation phase of the nurse-client relationship. D. Specifying a contract is a task the nurse should perform during the orientation phase of the nurse-client relationship.

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder and continually washes their hands. Which of the following interventions should the nurse recommend including in the plan? A. Inform the client that excessive handwashing is a negative behavior. B. Do not allow the client to use a private restroom. C. Schedule times for the client to wash their hands during the day. D. Explain that unit privileges will be taken away if excessive handwashing continues.

C. Schedule times for the client to wash their hands during the day. Rationale: Providing a schedule is a type of response prevention and can decrease anxiety by allowing the client to know in advance when handwashing can be performed. **A. Telling the client that excessive handwashing is a negative behavior can increase anxiety, rather than decrease the need for handwashing, and is not an effective intervention for the nurse to include in the plan of care. B. Not allowing the client to use a private restroom can increase anxiety, rather than decrease the need for handwashing, and is not an effective intervention for the nurse to include in the plan of care. D. Telling the client that privileges will be taken away is a negative intervention, which can increase anxiety, and is not an effective intervention to include in the plan of care.

A nurse in a long-term care center is caring for an adult client who has Alzheimer's disease and whose partner died several years ago. The client appears upset and asks the nurse when their partner will visit again. The nurses states, "It seems like you are feeling lonely. Let's take a walk outside and talk." Which of the following communication strategies is the nurse using? A. Reminiscence therapy B. Feedback C. Validation therapy D. Reflecting

C. Validation therapy Rationale: The nurse is using validation therapy as a strategy to communicate with the client. This strategy validates the client's feelings and emotions, even when they don't coincide with reality. The nurse should also attempt to integrate redirection techniques without the client realizing they are being redirected.

A nurse is preparing to administer Clozapine for the first time to a client who has schizophrenia. The nurse explains the therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts is the nurse demonstrating? A. Autonomy B. Justice C. Vercity D. Confidentiality

C. Vercity Rationale: Veracity is the duty to tell the truth. The nurse should uphold this ethical principle when administering a new medication to a client by explaining the therapeutic effects as well as the adverse effects. This action promotes a trusting relationship between the nurse and the client, which enhances the nurse's primary commitment to the client of providing optimum, quality care. **A. Autonomy involves respecting the client's right to make their own decision. The nurse is currently providing information. The client has not made a decision yet about taking the medication. B. Justice means distributing care or resources equally among clients or groups of clients. The nurse is currently caring for an individual client who requires information about a prescribed medication. D. Confidentiality means respecting the client's privacy regarding personal issues. The nurse should uphold this ethical principle when making decisions about sharing client information with others.

A nurse is caring for a client who takes Naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statements indicates the medication is effective? A. "Naltrexone calms my nerves." B. "I get flushed when I drink alcohol while taking naltrexone." C. "Naltrexone decreases my fine hand tremors." D. "I drink less alcohol in a day while taking naltrexone."

D. "I drink less alcohol in a day while taking naltrexone." Rationale: Clients who take naltrexone have a decreased craving for alcohol and experience decreased pleasurable effects from alcohol consumption. Although the goal for most clients who have alcohol use disorder is to maintain abstinence, clients who ingest alcohol while taking this medication often drink less per day. **A. Naltrexone is a narcotic antagonist, not an antianxiety medication. Anxiety is a potential adverse effect of this medication. B. A client can experience flushing with the concurrent use of alcohol and disulfiram. However, flushing is not an adverse effect of naltrexone. C. Benzodiazepine medications, such as chlordiazepoxide, are prescribed to decrease manifestations of alcohol withdrawal, such as hand tremors. Benzodiazepines also help stabilize the client's vital signs and decrease the risk for seizures. Naltrexone is not effective in treating manifestations of alcohol withdrawal.

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "This medication can cause dependence." B. "I'll take an extra dose of my medication when I start to feel anxious." C. "It's important to take my medication 30 minutes before bedtime." D. "I should expect my symptoms to improve in about 2 to 4 weeks."

D. "I should expect my symptoms to improve in about 2 to 4 weeks." Rationale: The nurse should instruct the client to expect some improvement of manifestations within approximately 1 week. However, it takes 2 to 4 weeks for buspirone to reach its full effect. **A. The nurse should instruct the client that buspirone does not cause psychological or physical dependence when taken as prescribed. B. The nurse should instruct the client to not take buspirone on a PRN basis or to take double doses in order to prevent adverse effects, such as insomnia, sedation, chest pain, or tachycardia. C. The nurse should instruct the client to take the medication as prescribed, which is usually in two divided doses in the morning and evening. It is not necessary for clients to take buspirone before bedtime.

A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statements indicates an understanding of the information? A. "I can expect my cigarette cravings to go away within 7 to 10 days." B. "I will likely feel like my heart is racing even when I'm resting." C. "I should increase my intake of calories because of the expected weight loss." D. "I will probably feel irritable within 24 hours of my last cigarette."

D. "I will probably feel irritable within 24 hours of my last cigarette." Rationale: The nurse should inform the client that withdrawal manifestations include irritability, craving, and difficulty concentrating. These manifestations typically start within 24 hr of the last cigarette or nicotine use. **A. The nurse should inform the client that nicotine withdrawal manifestations do not go away within 10 days but can last for weeks or months. B. Increased pulse rate and blood pressure occur due to release of norepinephrine and epinephrine in response to nicotine use. The nurse should inform the client to expect their heart rate to decrease as a common manifestation of nicotine withdrawal. C. The nurse should inform the client that weight gain is common with nicotine withdrawal due to an increased appetite.

A nurse in an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? A. A client who has schizophrenia is using neologisms. B. A client who has bipolar disorder is experiencing flight of ideas. C. A client who has depression avoids making eye contact. D. A client who has borderline personality disorder is pacing restlessly.

D. A client who has borderline personality disorder is pacing restlessly. Rationale: The nurse should identify that a client who has borderline personality disorder and is pacing restlessly is at increased risk for violence towards themselves or others. This behavior should be reported to the provider. **A. The nurse should identify that a client's use of neologisms is a common manifestation of schizophrenia and represents disorganized thinking. B. The nurse should identify that a client experiencing a flight of ideas is a common manifestation of bipolar disorder. The client's speech is rapid and changes instantaneously from one idea to the next. C. The nurse should identify that a client's failure to make eye contact is a common manifestation of depression. This can lead to social isolation.

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Increased yawning B. Bradycardia C. Hypersomnia D. Diaphoresis

D. Diaphoresis Rationale: The nurse should expect a client who is experiencing alcohol withdrawal to experience diaphoresis, or increased sweating.

A nurse is assisting with the planning of an interprofessional care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interprofessional treatment team should the nurse include? A. Occupational therapist B. Physician assistant C. Nurse researcher D. Dietitian

D. Dietitian Rationale: The nurse should plan to include the facility dietitian in an interprofessional care conference to assist with the creation of a treatment plan for a newly admitted client who has acute anorexia nervosa. A dietitian can evaluate the client to determine daily caloric intake requirements and the client's food likes and dislikes, which are necessary to achieve the client's target weight. A dietitian can also provide teaching to the client about nutrition.

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experience mania. Which of the following interventions should the nurse include to improve the client's nutritional status? A. Weigh the client at the same time every other day. B. Encourage the client to eat meals in the dining room with other clients. C. Request that the client keep a detailed food and beverage diary each day. D. Have finger foods available for the client in a quiet area.

D. Have finger foods available for the client in a quiet area. Rationale: The nurse should offer finger foods to the client in a quiet area to increase the client's nutritional intake. Because the client is moving and active, they are more likely to consume foods that they can eat quickly, which will improve the nutritional status of the client. **A. The nurse should offer finger foods to the client in a quiet area to increase the client's nutritional intake. Because the client is moving and active, they are more likely to consume foods that they can eat quickly, which will improve the nutritional status of the client. B. The nurse should direct the client to a quiet area with limited stimulation while they are experiencing mania. C. The nurse should monitor the client's intake and output daily. A client who is experiencing mania is unable to concentrate and regularly write in a food diary.

A nurse is developing countertransference toward a client during the working phase of the nurse-client relationship. To correct the situation, which of the following actions should the nurse take? A. Tell the client how to change their behaviors. B. Talk to the client about the developing feelings. C. Ask to be reassigned to a different client. D. Identify personal response to the client.

D. Identify personal response to the client. Rationale: Countertransference is an emotional response toward the client by the nurse. This response might be related to the nurse's past unresolved feelings or relationships. These feelings can interfere with the nurse-client therapeutic relationship. In order to correct the situation of countertransference, the nurse must recognize personal reactions to the client in an attempt to work through these feelings. **A. This action places responsibility on the client to correct the situation. When dealing with countertransference, it is the nurse's responsibility to find an appropriate solution. B. The nurse should avoid disclosing personal feelings because these feelings can interfere with the nurse-client relationship. When dealing with countertransference, it is the nurse's responsibility to find an appropriate solution, not the client's. C. In order to achieve personal and professional growth, the nurse should work through the issue of countertransference by caring for this client, rather than asking for a new assignment.

A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home. Which of the following actions should the nurse instruct to parent to take? A. Avoid enforcing a strict schedule for the child at home. B. Use biofeedback with the child. C. Give the child a PRN dose of methylphenidate. D. Initiate a point system for the child.

D. Initiate a point system for the child. Rationale: The nurse should instruct the parent to use tokens or points to reward desired behaviors and reduce maladaptive behaviors. A point system provides an incentive for the child to increase acceptable behaviors.

A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? A. Preoccupied with perfectionism B. Uses attention-seeking behaviors C. Exploitative of others D. Projects blame onto others

D. Projects blame onto others Rationale: The nurse should expect clients who have paranoid personality disorder to project blame onto others rather than taking responsibility for their own actions. **A. The nurse should expect a client who has obsessive-compulsive personality disorder to have manifestations of being preoccupied with details. B. The nurse should expect a client who has histrionic personality disorder to have manifestations of attention-seeking behaviors. C. The nurse should expect a client who has antisocial behavior to have manifestations of exploiting others.

A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? A. Summarize the goals achieved in the relationship. B. Plan for the initial interaction with the client. C. Establish the parameters of the relationship. D. Promote the development of problem-solving skills.

D. Promote the development of problem-solving skills. Rationale: The nurse should promote the development of problem-solving skills, promote behavioral change, and evaluate the client's progress during the working phase of the nurse-client relationship. **A. The nurse should summarize the achievement of goals during the termination phase of the nurse-client relationship. B. The nurse should plan for the initial interaction with the client during the preorientation and the orientation phases of the nurse-client relationship. C. The nurse should establish the parameters of the relationship during the orientation phase of the nurse-client relationship.

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following findings should the nurse expect? A. Hypotension B. Bradycardia C. Hypothermia D. Pupillary dilation

D. Pupillary dilation Rationale: The nurse should expect a client who is experiencing opioid withdrawal to have dilated pupils. Constriction of pupils is caused by anoxia. When clients begin the withdrawal process, the pupils relax, causing dilation to occur. These findings will gradually diminish over 5 to 10 days. **A. Hypertension is an expected manifestation for a client who is experiencing opioid withdrawal. B. Bradycardia is an expected manifestation for a client who is experiencing opioid intoxication. C. Hypothermia is an expected manifestation for a client who is experiencing opioid intoxication.

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa. EXHIBIT 1: Vital Signs Visit #1:​ BP 100/64 mm Hg Heart rate 62/min Respiratory rate 16/min Temperature 36.3° C (97.3° F) SaO2 98% Visit #2:​ BP 102/66 mm Hg Heart rate 56/min Respiratory rate 18/min Temperature 36.4° C (97.6° F) SaO2 99% EXHIBIT 2: Diagnostic Results Visit #1:​ ECG: Normal sinus rhythm Cholesterol: 196 mg/dL Platelet count: 155,000/mm3 (150,000 to 400,000/mm3) Visit #2:​ ECG: QT prolongation Cholesterol: 238 mg/dL Platelet count: 140,000/mm3 (150,000 to 400,000/mm3) EXHIBIT 3: Nurses' Notes Visit #1: Client reports taking laxatives daily and inducing vomiting 3 or 4 days per week. Client states, "I have always been a nervous person, even as a kid. I feel like I need to be perfect, or everyone will think I'm a complete failure. I can't believe I let myself gain this much weight - I look awful." BMI 16.8. Visit #2: Client reports no longer taking laxatives. Client also reports inducing vomiting most days and new onset of hematemesis. Petechiae noted on face and sclera. Client states, "I started therapy and have had two sessions so far. I also got some exercise equip

QT prolongation is correct. The client's ECG finding of QT prolongation during the second visit indicates cardiac complications of anorexia nervosa. Changes in electrolyte levels can shorten or prolong the QT interval. This is an indication that the client's condition is deteriorating. Exercise regimen is correct. The client's purchase of exercise equipment and working out twice per day is a new manifestation of anorexia nervosa. This is an indication that the client's condition is deteriorating. Hematemesis is correct. New onset of hematemesis might be caused by esophageal irritation or ulceration due to the client's increased frequency of induction of vomiting. Continued induction of vomiting can cause esophageal rupture. Therefore, hematemesis is an indication that the client's condition is deteriorating. Temperature is incorrect. The client's temperature has remained within the expected reference range. A decrease in body temperature with cool skin is an indication that the client's condition is deteriorating. Laxative use is incorrect. The client's cessation of the use of laxatives is an indication that the client's condition is improving. BMI is correct. The client's BMI decreased which indicates the client has continued to lose weight. This is an indication that the client's condition is deteriorating.

A nurse is preparing to administer Haloperidol 3mg IM to a client. Available is Haloperidol solution 5mg/mL. How many mL should the nurse plan to administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 3 mg Step 3: What is the dose available? Dose available = Have 5 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. ___mL = mL/5mg x 3mg/1 = 0.6 mL Step 7: Round if necessary.

A nurse is caring for a client who has alcohol use disorder. EXHIBIT 1: Vital Signs 0800 BP 116/68 mm Hg Pulse rate 80/min Respiratory rate 14/min Temperature 36.8° C (98.2° F) 1200 BP 120/84 mm Hg Pulse rate 96/min Respiratory rate 20/min Temperature 37° C (98.6° F) EXHIBIT 2: urses' Notes 0830Alert and oriented to time, place, person, and situation. Visiting with other clients in the dayroom. Attended group session this morning and states, "I think I'm beginning to see what I need to do to get better." Eager to have family visit with partner later this morning.1230Attended lunch with other clients but refused to eat or drink today. Staring intently at other clients and nursing staff. Posture is rigid and jaw is clenched.

The client is at greatest risk for ________ as evidenced by the client's ________. Dropdown 1: Ineffective coping is incorrect. The nurse should continue to monitor the client for ineffective coping and encourage the client to use coping techniques. However, this is not the greatest risk for this client. Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for this client. Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcohol which is causing increased agitation. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury. Dropdown 2: Agitation is correct. The client is at greatest risk of engaging in violent behavior as evidenced by the client's agitation, including pacing, restlessness, staring, silence, rigid posture, and clenched jaw. Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for the client. Loss of appetite is an expected finding for a client who is experiencing alcohol withdrawal. Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to perform simple tasks and encourage use of coping strategies. However, this is not the greatest risk for the client.

A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a selegiline 12 mg transdermal patch once daily. EXHIBIT 1: Nurses' Notes Tuesday: Client diagnosed with major depressive disorder 15 years ago. Visits clinic twice a week for outpatient group therapy with social worker and follow-up with nurse. Client actively participates in therapy. Acknowledges that relationship with family members has improved and there are fewer verbal altercations. Thursday: Client presents with irritability, flushed face, diaphoresis and severe headache and states, "I am really feeling bad. My heart is pounding." Was excited to share they had met a friend for lunch before coming to the clinic. Client states, "Maybe it's something I ate, but we both had the same thing, a corned beef sandwich with Swiss cheese. Do you think it is food poisoning?" EXHIBIT 2: Vital Signs Tuesday: Temperature 37° C (98.6° F) BP 114/78 mm Hg Heart rate 84/min Respiratory rate 16/min Thursday: Temperature 38.2° C (100.8 F°) BP 178/98 mm Hg Heart rate 128/min Respiratory rate 24/min

The client is at risk of developing _______ due to _______. Dropdown 1: Extrapyramidal side effects (EPS) is incorrect. EPS are movement disorders caused by first-generation antipsychotic medications. Selegiline is not an antipsychotic medication. Hypertensive crisis is correct. Selegiline is an MAOI medication used to treat depression. Clients who are taking MAOI medications should not consume foods that contain tyramine (aged cheese, yeast, smoked or aged meats) as this can cause a hypertensive crisis. Other manifestations of hypertensive crisis include chest pain, severe headache, nausea and vomiting, tachycardia, palpitations, and fever. Dry mouth is incorrect. Dry mouth is an anticholinergic reaction that can be caused by taking a tricyclic antidepressant. Selegiline is not a tricyclic antidepressant. Dropdown 2: Taking an antipsychotic medication is incorrect. Antipsychotic medications such as first-generation antipsychotics can cause extrapyramidal side effects. Selegiline is not an antipsychotic medication. Anticholinergic reaction is incorrect. An anticholinergic reaction can be caused by taking an SSRI. Selegiline is not an SSRI. Consuming foods high in tyramine is correct. The nurse should identify that consuming foods high in tyramine while taking an MAOI can lead to a hypertensive crisis. Selegiline is an MAOI medication used to treat depression. Clients who are taking MAOI medications should not consume foods that contain tyramine (aged cheese, yeast, smoked or aged meats). Other manifestations of hypertensive crisis include chest pain, severe headache, nausea and vomiting, tachycardia, palpitations, and fever.

A nurse on a mental health unit is admitting a client who has bipolar disorder.'' EXHIBIT 1: Vital Signs Day 1, admission at 2000: BP 158/98 mm Hg Heart rate 104/min Respiratory rate 20/min Temperature 37.4° C (99.3° F) SaO2: 98% Day 2, 1000: BP 158/98 mm Hg Heart rate 134/min Respiratory rate 24/min Temperature 37.7° C (99.9° F) SaO2: 97% EXHIBIT 2: Medical History Day 1, admission at 2000:Client was diagnosed with bipolar I disorder 3 years ago. Client was hospitalized for mania at time of diagnosis. Client manages condition with medication and outpatient treatment.Client had tonsillectomy at 4 years of age and was hospitalized for pneumonia 5 years ago. EXHIBIT 3: Nurses' Notes Day 1, 2000 admit note: Client talkative during admission interview. Tapping feet, frequently fidgeting in chair. Occasionally laughs inappropriately. Client wearing jeans, two sweatshirts, knit stocking cap, heavy socks, and boots despite outdoor temperature of 26.7° C (80° F). Client reports they're not sure when they last took their medication and states, "I've been doing fine, so I thought I would see how I feel without it." Client unsure when they last ate but denies feeling hungry. Day 2, 1000: Client

The first action the nurse should take is to address the client's ______ due to the client's ______. Dropdown 1: Urine output is incorrect. The nurse should monitor the client's intake and output since clients who are experiencing mania are at risk for dehydration and malnutrition. However, there is another action the nurse should take first. Risk for cardiovascular injury is correct. The greatest risk to the client is cardiovascular injury and death due to severe exhaustion from excessive physical activity, lack of sleep, and poor food and fluid intake. The client's blood pressure and heart rate are above the expected reference ranges, indicating unexpected cardiovascular findings. Therefore, addressing the client's risk for cardiovascular injury is the first action the nurse should take. Noncompliance with medication therapy is incorrect. The nurse should further investigate the client for noncompliance with lithium therapy to determine if it is the cause of the manic episode. However, there is another action the nurse should take first. Inability to focus is incorrect. The nurse should also address the client's inability to focus by redirecting the client on the conversation using therapeutic communication. However, there is another action the nurse should take first. Dropdown 2: Pressured speech is incorrect. Pressured speech is an expected finding for a client who is experiencing mania. However, the nurse should address another finding first. Poor recall of last food intake is incorrect. The nurse should monitor the client's food and fluid intake due to the client's poor recall of last food intake and minimal fluid intake since admission. However, the nurse should address another finding first. Constant psychomotor activity is correct. The greatest risk to the client is cardiovascular injury due to constant and excessive psychomotor activity. The client is pacing, moving arms and hands around dramatically, and is unable to sit still, which can lead to poor intake and output, malnutrition, and eventual cardiovascular injury. Therefore, the nurse should first address the client's psychomotor activity. Lithium level is incorrect. The nurse should also report the lithium level to the provider as is it