NURSING 307ATI RN Mental Health Online Practice 2019 B - WeeK 10, Exams of Health sciences

Download NURSING 307ATI RN Mental Health Online Practice 2019 B - WeeK 10 and more Exams Health sciences in PDF only on Docsity! ATI RN Mental Health Online Practice 2019 B PSY Week 10 10/27/21 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 - The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine. A nurse is planning discharge teaching with a family member of a client who has 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 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 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 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 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 caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effects of methylphenidate? A. Weight gain B. Tinnitus C. Tachycardia D. Increased salvation C. Tachycardia - The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate. A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others or 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 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 nurse is education 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 - The nurse should identify that language delays are a manifestation of autism spectrum disorder. 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 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 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 - A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting. C. An adolescent who has a vaginal candida infection D. A young adult who is pregnant and has a sprained ankle A. Inform the client that this administration 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. B. Introduce the client to other clients in the day room C. Assist the client in facilitation behavior change D. Determine coping strategies that the client has used in the past 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. - 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 at a providers office is interviewing an older adult client. Which of the following actions should the nurse plan to take? Nurse's Notes: 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. Graphic Results: SaO2 96% on room air Respiratory rate 20/min Blood pressure 112/76 mm Hg (lying) Blood pressure 104/68 mm Hg (standing) Heart rate 68/min Temperature 36° C (96.8° F) Medication Administration Record: Captopril 12.5 mg by mouth three times daily Digoxin 0.125 mg by mouth each morning Multivitamin with iron one by mouth daily Docusate sodium 50 mg by mouth each evening 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 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 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. - Include a liquid supplement for someone who is below their ideal body weight and might not eat solid foods or might need the additional nutrition to gain weight. 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. C. Allow the client at least 1 hr for each meal. - Limit meals to 30 mins to prevent putting excessive focus on foods. D. Weigh the client at bedtime each day. - Pt should be weighed in morning and void prior to oral intake. RN should weigh pt daily for 1st week then 3 x per week after that. A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following client 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 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 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." - The nurse should update the plan of care as a client's status and needs change. D. "An assistive personnel can use the plan of care for client teaching." 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 - 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. C. Onset of frequent, loose stools D. Development of physiologic dependence on the medication 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) - An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy. B. Increase low-density lipoproteins (LDL) C. Decreased fasting blood glucose D. Decreased aspartate aminotransferase (AST) 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. 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 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 - 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. B. Veracity C. Justice D. Autonomy 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 - 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 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 - 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. C. Reports of fatigue D. Isolation from others 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 - 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. C. Pinpoint pupils D. Blood glucose 210 mg/dL 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 - Extreme distractibility is a hallmark manifestation of delirium. A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish men 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." - The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling. D. "You shouldn't say things that will upset you so much." A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking orders. 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 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 - Not a risk. B. The client recently received a promotion at work - Presence of a negative life event rather than a positive life event is a risk factor for development of depression. C. The client has COPD D. The client is a male - Female, not males, are at higher risk. 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 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. - This is an ex of primary prevention. Positive coping mechanisms help pt’s and their partners cope with stress and help to prevent the incidence of partner violence in the community. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. - This is tertiary prevention. This takes place after the violence has occurred. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse. - This is an ex of tertiary prevention. This takes place after partner violence has occurred & facilitates support and rehab for the pt. 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 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.) x mL = 1.5 Follow these steps for the Desired Over Have method of calculation: 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 7.5 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. X = (Desired × Quantity) / Have X = (7.5 mg × 1 mL) / 5 mg X mL = 1.5 Step 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 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 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 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 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 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. This pt is at risk for self-harm and feel isolated, moving this pt is not a good idea. 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 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/mm B. Hgb 11.5 mg/dL - This drug doesn’t affect Hgb levels. C. Platelets 150,000/mm - This is WNL. D. RBC count 3.5 million/mm - This drug does not affect RBC levels. 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/mm^3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.