PN Mental Health Online Practice 2020 A

6 September 2022
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question
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. Incorrect (The client will receive oxygen throughout the procedure. However, the oxygen will be removed during the brief electrical stimulation intervals.) b. A benzodiazepine will be administered prior to the procedure. Incorrect (A benzodiazepine should not be administered because it interferes with the seizure process. A short-acting anesthetic, such as propofol, will be administered.) c. ECT is an option for clients after medication has been unsuccessful. d. Confusion is expected for the first 2 days after treatment. (Clients who receive ECT can have confusion and disorientation for several hours after treatment.)
answer
C. ECT is an option for clients after medication has been unsuccessful. (Medication is the first-line of treatment for depression. ECT is prescribed when medication has been unsuccessful.)
question
A nurse is assisting with discharge planning for a client who needs to attend a day treatment center ad 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(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. Psychologist (Although psychologists can provide individual or family therapy for clients, they do not usually address issues regarding financial support and community resources.) D. Pharmacist (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.)
answer
A. Social worker (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.)
question
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. (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. Talk to the client about the developing feelings. (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. Ask to be reassigned to a different client. (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.) D. identify personal response to the client.
answer
D. identify personal response to the client. (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.)
question
A nurse is collecting data from a client who has bipolar 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 (Weight loss, rather than weight gain, can indicate relapse in a client who has a history of mania.) B. Pressured speech C. Ritualistic behavior (Ritualistic behavior is an indication of obsessive-compulsive disorder, not mania.) D. Anhedonia (Anhedonia is a negative symptom of schizophrenia. Anhedonia is defined as a loss of interest in daily activities and the inability or lack of capacity to experience pleasure in general. This is not an indication of relapse in a client who has a history of mania.)
answer
B. Pressured speech (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.)
question
History and Physical Subjective: Client states, "My stomach hurts."; "I feel sadder and more alone every day." Client's adult child stated to the nurse upon dropping the client off today, "I've been meaning to tell you, I started giving my dad St. John's wort several weeks ago to improve his mood." Objective: Episodes of speech incoherency, rapid mood swings, 3 episodes of vomiting in the past 40 min Moderate Alzheimer's disease. Provider Prescriptions Fluoxetine 20 mg PO daily Trazodone 50 mg PO daily at bedtime Omeprazole 20 mg PO daily Diagnostic Results Blood pressure 172/94 mm Hg Temperature 38.2ยฐ C (100.8ยฐ F) Pulse rate 110/min Respiratory rate 24/min A nurse is caring for a client in a day treatment program. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data) A. Request transport for the client to an emergency department. B. Place a hypothermia blanket on the client. (There is no indication that a hypothermia blanket is necessary for this client.) C. Discontinue the client's fluoxetine therapy immediately. (Fluoxetine should not be discontinued abruptly because this can cause the client to exhibit manifestations of withdrawal.) D. Implement droplet precautions for the client. (There is no indication for the implementation of droplet precautions for this client. Droplet precautions are used for clients who have diseases that are transmitted by large droplets that are expelled into the air.)
answer
A. Request transport for the client to an emergency department. (The nurse should request transport for the client to the nearest emergency department because the client has manifestations of serotonin syndrome. Serotonin syndrome is a life-threatening syndrome and is caused by an over activation of the central serotonin receptors. This is related to interactions with taking an SSRI and trazodone along with St. John's wort. Manifestations of serotonin syndrome include hypertension, tachycardia, vomiting, abdominal pain, and mental status changes.)
question
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 (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 (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.) C. Veracity D. Confidentiality (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.)
answer
C. Veracity (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.)
question
A nurse is preparing to administer haloperidol 3 mg IM to a client. Available is haloperidol solution 5 mg/mL. How many mL should the nurse plan to administer?
answer
5 mg3 mg = 1 mL X mL X mL = 0.6 mL Step 7: Round if necessary
question
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." (This response devalues the client's concerns, gives false reassurance, and discourages further communication about the motivation behind the client's refusal.) B. "You have the right to refuse this medication." C. "You are presenting a risk to the other clients." (This response places blame on the client and rejects their choice without exploring the motivation behind it.) D. "This medication is part of your treatment plan." (This response fails to encourage the client to explore their feelings of anxiety and to participate in devising or accepting strategies to manage it)
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B. "You have the right to refuse this medication." ( 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.)
question
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 (The nurse should expect a client who has obsessive-compulsive personality disorder to have manifestations of being preoccupied with details.) B. Uses attention-seeking behaviors (The nurse should expect a client who has histrionic personality disorder to have manifestations of attention-seeking behaviors.) C. Exploitative of others (The nurse should expect a client who has antisocial behavior to have manifestations of exploiting others.) D. Projects blame onto others
answer
D. Projects blame onto others (The nurse should expect clients who have paranoid personality disorder to project blame onto others rather than taking responsibility for their own actions.)
question
A nurse is caring for a client who is 2 days post-op following a hip arthroplasty. When a news report about military action comes 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." 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.) D. "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.) E. "Tell me something you remember about your child."
answer
A. "This must be a very difficult time for you." (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.) B. "Your child's death must be a terrible loss." (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.) E. "Tell me something you remember about your child." (This statement demonstrates the use of exploring. Exploring acknowledges the client's feelings and facilitates communication between the client and the nurse.)
question
A nurse is assisting with screening a group of clients for 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. (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. A client who abstains from alcohol (Clients who have alcohol or substance use disorders are at an increased risk for developing MDD.) C. A client who just gave birth D. A client who has been married for 15 years (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)
answer
C. A client who just gave birth (Clients who just gave birth or are in the early postpartum period are at an increased risk for developing MDD or postpartum depression.)
question
A nurse is assisting with the admission of a client who has schizophrenia. A. Conduct an abnormal involuntary movement scale 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. Orient the client to unit routines. (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. Encourage the client to attend group art sessions. (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)
answer
A. Conduct an abnormal involuntary movement scale test. (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.)
question
A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder and continually washes her hands. Which of the following interventions should the nurse include? A. Inform the client that excessive handwashing is a negative behavior. (This 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. Do not allow the client to use a private restroom. (This can increase anxiety) 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. (This can increase anxiety)
answer
C. Schedule times for the client to wash their hands during the day. (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.)
question
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 (This affects the client's concentration, which decreases the client's ability to complete tasks. However, another finding is the priority to report.) B. Anhedonia (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.) C. Feelings of hopelessness D. Fatigue (indicates that the client is at risk for inability to complete ADLs. However, another finding is the priority to report)
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C. Feelings of hopelessness (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.)
question
A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse include? A. Occupational therapist (works with clients who have impaired functioning and assists in the performance of ADLs. However, there is no indication that a client who has acute anorexia nervosa requires occupational therapy. Therefore, a client who has acute anorexia nervosa does not require an occupational therapist.) B. Physician assistant(performs tasks under the supervision of the physician and provides primary care in the physician's office.) C. Nurse researcher (can conduct research about the nursing care of clients who have mental health disorders) D. Dietitian
answer
D. Dietitian (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.)
question
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 (The nurse should monitor clients who have bulimia nervosa for hypochloremia, not hyperchloremia.) B. Hyponatremia C. Decreased bone density (Decreased bone density is a potential complication of anorexia nervosa, not bulimia nervosa.) D. Increased WBC count (An increased WBC count is an indication of infection. However, this is not an expected complication of bulimia nervosa.)
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B. Hyponatremia ( The nurse should monitor clients who have bulimia nervosa for hyponatremia, which results from purging, vomiting, and laxative and/or diuretic use.)
question
A nurse is caring for a client 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." (Naltrexone is a narcotic antagonist, not an antianxiety medication.) B. "I get flushed when I drink alcohol while taking naltrexone." (A client can experience flushing with the concurrent use of alcohol and disulfiram. However, flushing is not an adverse effect of naltrexone.) C. "Naltrexone decreases my fine hand tremors." D. "I drink less alcohol in a day while taking naltrexone."
answer
D. "I drink less alcohol in a day while taking naltrexone." (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.)
question
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.
answer
B. The nurse places the client's diagnosis on the whiteboard in the client's room. (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.)
question
A nurse is reinforcing teaching with a client who has schizophrenia 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." (Chlorpromazine causes sedation) C. "You should now be able to spend more time in the sun." D. "Call your provider immediately if you develop a dry mouth."
answer
A. "The voices you have been hearing should decrease." (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.)
question
A nurse is caring for an older adult client who is about to undergo screening with the mental status examination (MSE). The client asks about the purpose of this test. Which of the following responses should the nurse make? A. "We're just going to ask you some very simple questions." (This response by the nurse is changing the subject, which is nontherapeutic communication and does not address the client's concerns.) B. "This test will collect information about your family history." (The MSE does not require information about family history. It is an assessment of the client's current memory, speech, and cognition.) C. "You are going to be okay. There is nothing to worry about." (This response by the nurse is providing false reassurance) D. "This test will give us information about how you remember things."
answer
D. "This test will give us information about how you remember things." (The MSE tests the cognitive function of the client. It is an assessment of the client's current memory, speech, and cognition.)
question
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. (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. Administer a sedative to the client. (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.) C. Determine the client's intentions. D. Place the client into the assigned seclusion room. (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.)
answer
C. Determine the client's intentions. (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.)
question
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 social worker!" The nurse should identify the client is using which of the following defense mechanisms? A. Reaction formation B. Dissociation (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 (Denial is the defense mechanism in which the client ignores unpleasant or anxiety-producing events to decrease anxiety.) D. Projection (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.)
answer
A. Reaction formation (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.)
question
A nurse is caring for an adult client who has visible injuries as a result of intimate 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. (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.) B. Encourage the client to develop a safety plan. C. Recommend that the partner remain in the room during the interview with the client. (The nurse should interview the client privately without the partner present.) D. Advise the client to obtain an order of protection from the court. (Giving advice is not a therapeutic technique. The nurse should offer support for the client's own decisions and refrain from offering advice)
answer
B. Encourage the client to develop a safety plan. (The nurse should encourage the client to develop a safety plan to aid in escaping further violence if necessary.)
question
A nurse is caring for a client who has bipolar disorder 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. (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. Administer an antipsychotic medication to the client. (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. Provide physical activities for the client. (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.)
answer
A. Remove harmful objects from the client's room. (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.)
question
A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She 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."
answer
C. "It is important to share what you are feeling, even if it is anger." (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.)
question
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 rapport. (Establishing rapport is a task the nurse should perform during the orientation phase of the nurse-client relationship.) B. Explain confidentiality and privacy. (Explaining confidentiality is a task the nurse should perform during the orientation phase of the nurse-client relationship.) C. Reinforce teaching about medication. D. Specify a contract. (Specifying a contract is a task the nurse should perform during the orientation phase of the nurse-client relationship.)
answer
C. Reinforce teaching about medication. (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.)
question
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. (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.) C. A nurse administers an anti-anxiety medication to a restless client who has given implied consent. (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.) D. A nurse does not document the completion of an incident report about a recent fall in the client's medical record. (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.)
answer
A. A nurse does not notify the provider of a change in condition for a client who has schizophrenia. (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.)
question
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." (This statement describes systematic desensitization, not thought stopping.) 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." (This statement describes modeling, not thought stopping.) D. "I will ride in a car for several hours at a time." (This statement describes flooding, not thought stopping.)
answer
B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car." (This statement describes thought stopping, which is used to interrupt a client's negative thought with a distraction.)
question
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 ( 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 (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.) C. Apathy D. Paranoia (Paranoia is an unfounded fear of others and is a positive symptom of schizophrenia.)
answer
C. Apathy (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.)
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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 the parent to take? A. Avoid enforcing a strict schedule for the child at home. (Children who have ADHD follow a strict schedule in the school environment, which helps to decrease the anxiety level of the child. Consistency in the home environment is important to ensure success in decreasing disruptive behaviors and facilitates trust between the child and the parent or guardian. The nurse should instruct the parent to provide a highly structured environment for the child at home.) B. Use biofeedback with the child. (Biofeedback is used to decrease stress in adult clients who have anxiety disorders and requires specialized training and the ability to focus on physical sensations of the body during stress. The nurse should instruct the parent to use modeling, limit-setting, or redirection with the child.) C. Give the child a PRN dose of methylphenidate. (Methylphenidate is not approved for administration on a PRN basis. The nurse should instruct the parent that methylphenidate is a stimulant medication that is given on a scheduled basis, usually once or twice per day.) D. Initiate a point system for the child
answer
D. Initiate a point system for the child (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.)
question
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with 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."
answer
D. "I should expect my symptoms to improve in about 2 to 4 weeks." ( 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.)
question
A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect? A. Amenorrhea (is a manifestation of anorexia nervosa that is caused by a fluid and electrolyte imbalance.) B. Dental caries C. Lanugo (Lanugo is a manifestation of anorexia nervosa that is caused by starvation.) D. Yellow skin (Yellow skin is a manifestation of anorexia nervosa that is caused by carotenemia.)
answer
B. Dental caries (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.)
question
A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania. Which of the following interventions should the nurse include to improve the nutritional status of the client? A. Weigh the client at the same time every other day. (The nurse should weigh the client as close to the same time as possible daily to monitor for weight loss due to increased physical activity and exertion.) B. Encourage the client to eat meals in the dining room with other clients. (The nurse should direct the client to a quiet area with limited stimulation while they are experiencing mania.) C. Request that the client keep a detailed food and beverage diary each day. (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.) D. Have finger foods available for the client in a quiet area.
answer
D. Have finger foods available for the client in a quiet area. (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.)
question
A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following findings should the nurse expect? A. Hypotension (Hypertension is an expected manifestation for a client who is experiencing opioid withdrawal.) B. Bradycardia (Bradycardia is an expected manifestation for a client who is experiencing opioid intoxication.) C. Hypothermia (Hypothermia is an expected manifestation for a client who is experiencing opioid intoxication.) D. Pupillary dilation
answer
D. Pupillary dilation (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.)
question
A nurse on an inpatient unit is assisting with a group therapy session. During the session, a client begins to shout, using aggressive language. Which of the following statements should the nurse make to the client? A. "Why do you feel the need to speak this way to others in the group?" (This is an example of a "why" question that implies criticism of the client, which can cause the client to react defensively.) B. "When you raise your voice, it makes me feel uncomfortable and unsafe." C. "You are frightening others in the group when you show your anger." (This is an example of showing disapproval, which can cause the client to react defensively. Also, with this statement, the nurse is speaking for the other members of the group.) D. "Why are you attending group therapy but not respecting the feelings of others?" (This is an example of a "why" question that implies criticism to the client. Also, it makes a value judgment, which can cause the client to feel guilty and angry.)
answer
B. "When you raise your voice, it makes me feel uncomfortable and unsafe." (Using "I feel" messages models the sharing and owning of personal feelings and helps minimize defensive responses.)
question
A nurse in a provider's office is collecting data from an older adult client whose adult child reports that she "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. (A client who has depression would exhibit an exacerbation of confusion during times of stress.) B. The client's level of consciousness changes during the interview. C. The client's confusion improves in the evening. (The client's confusion will worsen in the evening, and the sleep-wake cycle might be reversed.) D. The client has a flat affect during the interview. (A client who has depression would exhibit a flat affect and be slow to respond when speaking.)
answer
B. The client's level of consciousness changes during the interview. (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.)
question
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. (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. Assist a client who has a depressive disorder with decision making regarding group activities. (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. Reinforce teaching about a new prescription of clozapine with a client who has schizophrenia. (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.)
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A. Offer finger foods to a client who is in the manic phase of bipolar disorder. (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.)
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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 statement indicates an understanding of the information? A. "I can expect my cigarette cravings to go away within 7 to 10 days." (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. "I will likely feel like my heart is racing even when I'm resting." (Increased pulse rate and blood pressure occur due to the 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. "I should increase my intake of calories because of the expected weight loss." (The nurse should inform the client that weight gain is common with nicotine withdrawal due to an increased appetite.) D. "I will probably feel irritable within 24 hours of my last cigarette."
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D. "I will probably feel irritable within 24 hours of my last cigarette." (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.)
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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 manifestations is an indicator of the client's use of the substance? A. Hypertension B. Drowsiness (Mental alertness is an expected finding of cocaine use.) C. Bradycardia (Tachycardia is an expected finding of cocaine use.) D. Constricted pupils (Dilated pupils are an expected finding of cocaine use.)
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A. Hypertension (Cocaine is a central nervous system stimulant. Therefore, hypertension is an expected finding.)
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A nurse is collecting data from a client who is having difficulty coping with the death of his child. Which of the following questions by the nurse is the priority? A. "What events led you to seek help?" B. "Who can you turn to for support?" C. "Do you think about harming yourself?" D. "Which activities help you to have better days?"
answer
C. "Do you think about harming yourself?" (The nurse should identify that the greatest risk to this client is self-injury from suicide. Therefore, the priority intervention is to ensure the client's safety. The best way the nurse can accomplish that at this time is to determine if the client has thoughts of self-harm.)
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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. (The nurse should provide a handkerchief to a client who has pseudoparkinsonism, not akathisia.) B. Initiate seizure precautions. C. Administer an antiparkinsonian agent. D. Implement emergency cooling measures.
answer
C. Administer an antiparkinsonian agent. (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.) Akathisia is an extra-pyramidal movement disorder characterized by a need to be in constant motion. Patients exhibit movements including rocking while sitting or standing, lifting the feet as if marching while standing, or crossing and uncrossing the legs while sitting in a chair.
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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.
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A. Establish and explain consequences for the client's behavior. (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.)
question
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."
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C. "How is an orange similar to an apple?" (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.)
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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 (tachcardia) C. Hypersomnia (insomnia) D. Diaphoresis
answer
D. Diaphoresis
question
A nurse is caring for a client who is 2 days post-op following a hip arthroplasty. When a news report about military action comes 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." (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) D. "You need to focus on getting better." (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.) E. "Tell me something you remember about your child."
answer
A, B, and D A. "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. B. "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. D. "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)
question
A nurse on 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. (The nurse should identify that a client's use of neologisms is a common manifestation of schizophrenia and represents disorganized thinking.) B. A client who has bipolar disorder is experiencing flight of ideas. ( Bipolar disorders) C. A client who has depression avoids making eye contact. (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) D. A client who has borderline personality disorder is pacing restlessly.
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D. A client who has borderline personality disorder is pacing restlessly. (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.)
question
A nurse in 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. (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. Apply wrist restraints.
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B. Offer diversionary activities. (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.)
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(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. (The nurse should summarize the achievement of goals during the termination phase of the nurse-client relationship.) B. Plan for the initial interaction with the client. (The nurse should plan for the initial interaction with the client during the preorientation and the orientation phases of the nurse-client relationship.) C. Establish the parameters of the relationship. (The nurse should establish the parameters of the relationship during the orientation phase of the nurse-client relationship.) D. Promote the development of problem-solving skills.
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D. Promote the development of problem-solving skills. (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.)
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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."
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A. "We will demonstrate for you how to use relaxation techniques."
question
A nurse is collecting data from a newly admitted client. Which of following questions should the nurse include to gather psychosocial information? A. "Do you have a hobby that you enjoy?" B. "What is the date and where are you living?" (The nurse collects data regarding cognition and orientation when conducting a mental status examination, not a psychosocial examination.) C. "How are an apple and an orange alike?" (The client's response to this question provides information about the client's cognition and is part of a mental status examination, not a psychosocial examination.) D. "Can you take this pencil and put it in the cup?" (This question evaluates the client's ability to follow a verbal command and is part of a mental status examination, not a psychosocial examination.)
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A. "Do you have a hobby that you enjoy?" (The nurse should ask questions regarding the client's interests and hobbies when gathering psychosocial information.)
question
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 his partner will visit again. The nurse 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 (Reminiscence therapy encourages the client to reflect on and think about the past. This therapy most often takes place in a group setting where older adult clients share significant past events with their peers.) B. Feedback (Feedback gives information to clients about how others perceive them and helps them consider changing their behavior.) C. Validation therapy D. Reflecting (Reflecting refers questions and feelings back to client, so they realize that their point of view has value. This technique is used most often when clients ask the nurse for advice.)
answer
C. Validation therapy ( 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.)