ATI Mental Health Proctored Exams ALL LATEST 13 CHAPTERS AVAILABLE

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Mental Health Version-1 5) A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Encourage th... e client to join group activities b. Dim the lights in the clients room c. Provide detailed explanations to the client d. Administer methylphenidate 6) A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first. a. Initiate referrals b. Review community resources c. Identify prior coping skills d. Discuss the importance of confidentiality 7) A nurse overhears a client saying, "I am a spy, a spy for the FBI. I am an I, an eye for an eye in the sky. Sky is up high." The nurse should document the client's statement as which of the following speech alterations? a. Echolalia b. Word salad c. Neologism d. Clang association 8) An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states "I'm so worried that my mother is depressed" which of the following responses should the nurse make? a. Everyone gets depressed from time to time. b. You shouldn't worry about this because depressive disorder is easily treated. c. Older adults are usually diagnosed with depressive disorder as they age. d. Tell me the reasons you think your mother is depressed. 9) A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan care? a. Meets own needs without manipulating others. b. Initiates social interactions with caregivers. c. Changes behavior as a result of peer pressure. d. Acknowledges his delusions are not real. 10) A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Snap a rubber band on your wrist when you think about checking the locks. b. Ask a family member to check the locks for you at night. c. Focus on abdominal breathing whenever you go to check the locks. d. Keep a journal of how often you check the locks each night. 11) A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicate the nurse is practicing the ethical principle of nonmaleficence? a. Provide the client with quality care regardless of their ability to pay for treatment. b. Educating the client about legal rights concerning treatment. c. Withholding the prescribed medication that is causing adverse effects for the client. d. Being truthful with the client about the manifestations of withdrawl. 12) A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use? a. Crisis intervention to decrease anxiety. b. Aversion therapy to provide distraction c. Positive reinforcement to increase desired behavior. d. Systematic desensitization to extinguish the behavior. 13) A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a. Ask the client to discuss precipitating events b. Speaks to the client in a high-pitched voice. c. Place the client in seclusion d. Have the client breathe into a paper bag. 14) The nurse is caring for a client following a physical assault. The client states "I don’t remember what happened to me." The nurse should recognize that the client is using which of the following defense mechanisms? a. Repression b. Displacement c. Rationalization d. Denial 15) A nurse is caring for a client who has anorexia nervosa. Which of the following findings require immediate intervention by the nurse? a. +2 edema of the lower extremities b. BUN 21 mg/dL c. Lanugo covering the body d. Blood pH 7.60 16) A nurse is caring for a client in a mental health facility. The client is agitated and threatens to harm herself and others. Which of the following is the priority intervention? a. Place the client in restraints b. Administer an anti-anxiety medication to the client c. Put the client in seclusion d. Set limits on the client's behavior 17) Dosage Calculation Question. 18) A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take? a. Ask the clients family to encourage the client to receive ECT b. Inform the client that ECT does not require a consent. c. Document the client's refusal of the treatment in the medical record. d. Tell the client he cannot refuse the treatment because he was involuntarily committed. 19) A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first? a. Request a mental health consult for the client. b. Ask the client if she has thought about harming herself. c. Encourage the client to attend a grief support group. d. Discuss the clients coping skills. 20) A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups. a. Dual diagnosis treatment group b. Dialectical treatment group c. Desensitization therapy d. Co-dependents support group. 21) The nurse is reviewing the medication administration record of a client who has schizophrenia. The nurse should plan to initiate the Abnormal Involuntary Movement Scale to monitor for adverse effects of which of the following medications.? a. Amantadine b. Diphenhydramine c. Benztropine d. Haloperidol 22) A nurse is counseling a client following the death of a clients partner 8 months ago. Which of the following client statements indicates maladaptive grieving? a. I am so sorry for the times I was angry with my partner. b. I find myself thinking about my partner often. c. I still don't feel up to returning to work. d. I like looking at his personal items in the closet. 23) A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan? a. The client will report a decrease in hallucinations. b. The client will communicate needs c. The client will verbalize improved mood d. The client will attend to personal hygiene. 24) A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states "I can't stand to be touched by another person." Which of the following responses should the nurse make? a. Why don’t you like to be touched by others b. Don’t worry about it. Your anxiety will lessen once the massage begins. c. I will tell your provider you would like a treatment other than a massage. d. I will request that the massage therapist wear gloves during your treatment. 25) A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? a. Encourage physical activity for the client during the day b. Discourage the client from expressing feelings of anger c. Keep a bright light on in the client's room at night. d. Identify and schedule alternative group activities for the client. 26) A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role as the monopolizer? a. The mother who expresses hostility toward her spouse. b. The adolescent son who refuses to share personal feelings. c. The father who intervenes whenever the siblings argue. d. The adolescent daughter who attempts to dominate the conversation. 27) A nurse is developing a teaching plan for the family of an older adult client who is to receive transcranial magnetic stimulation. Which of the following information should the nurse include in the teaching plan? a. The client might have a headache after treatment. b. The client will experience seizure during treatment. c. The client will require intubation after treatment. d. The client is at risk for aspiration during treatment. 28) A nurse is providing teaching about disulfiram to a client who has a history of alcohol use. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. “You will need to take the medication once daily” b. “you will receive treatment in an inpatient setting” c. “You should avoid using mouthwash that contains alcohol” d. “you should avoid drinking carbonated beverages while taking the medication” e. “you can expect to develop a physical dependence to the medication” 29) A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take? a. Avoid power struggles by remaining neutral b. Allow the client to set limits for his behavior c. Provide in-depth explanation of nursing expectations d. Encourage the client to participate in group activities 30) A nurse is assessing a young adult female client for schizophrenia. Which of the following findings should the nurse identify as a risk factor for this condition? a. Environmental stress b. Gender c. Depression d. Birth order 31) A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching? a. The client exhibits an inflated sense of self b. The client develops an inability to concentrate c. The client increases participation in social activities d. The client begins sleeping more than usual 32) A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium? a. The client is unable to recognize objects. b. The client manifestations developed suddenly c. The client has a flat affect d. The client’s speech is slow and repetitious 33) A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make? a. “ You know that’s not true, because it is against the law for others to read your mail” b. “All of your letters come sealed, so that seems unlikely” c. “It must be frightened to think that someone is reading your mail” d. “Why do you think the government wants to read your mail?” 34) A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the following clinical findings should the nurse expect? a. Heart rate 48/min b. Temperature 40 C (104 F) c. WBC 3,000/mm3 d. Hypotonicity 35) A nurse is reviewing the medical record of a client who is taking clozapine. For which of the following findings should the nurse withhold the medication and notify the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. WBC count b. Blood glucose level c. Report of photosensitivity d. Heart Rate 36) A nurse is caring for a client who has personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect? a. Talking negatively about other staff members b. Expressing frustration regarding unit rules c. Reacting to the nurse as though she were his mother d. Refusing to participate in group activities 37) A nurse in a mental health facility is caring for a newly admitted client. Which of the following resources should the nurse recommend to help the client adapt to the health care setting? a. A community meeting b. A medication group c. A self-help meeting d. A symptom-management group 38) A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Request that the client’s guardian sign the consent b. Ask the charge nurse to obtain informed consent c. Contact the facility social worker to obtain the consent d. Explain implied consent to the client’s family 39) A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? a. Hand tremors b. Rapid speech c. Fatigue d. Seizures 40) A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching? a. “Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD” b. “Talking about the traumatic experience is recommended” c. “Response prevention is an effective treatment for PTSD” d. “You should try to limit the number of hours that you sleep each day” 41) A nurse is assessing a client who has bipolar disorder and is taking lamtropine. Which of the following findings is the nurse’s priority? a. Thyroid-stimulating hormone (TSH) 4.0 microunits/mL b. Alanine transaminase (ALT) 20 IU/L c. Skin rash d. Epistaxis 42) A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of the disorder. Which of the following actions should the nurse take? a. Manage the client’s loud, rambling, and incoherent communication patterns b. Direct the client to perform her own daily hygiene and grooming tasks c. Assist the client to identify somatic and thought-broadcasting delusions d. Use medication to decrease frequency of auditory and visual hallucination. 43) A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase? a. Inform the client about confidentiality rights b. Establish boundaries between the nurse and the client c. Set short and long-term objectives for the future d. Evaluate progress toward predetermined goals 44) A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Occupational therapist d. Social worker 45) A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanism is the client demonstrating? a. Denial b. Displacement c. Compensation d. Rationalization 46) A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference? a. “The client is just like my brother who finally overcame his habit” b. “The client needs to accept responsibility for his substance use” c. “The client generally shares his feelings during group therapy session” d. “The client asked me to go on a date with him, but I refuse” 47) A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first? a. Establish a rapport to foster trust b. Implement continuous one-to-one observation c. Ask the client to sign a no-suicide contract d. Encourage the client to participate in group therapy 48) A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanism. Which of the following examples should the nurse include in the teaching? a. A student who is upset with her teacher writes a story about an excellent student b. A school-age child whose mother died 2 years ago talks about her in present tense. c. A woman who has health concern postpones a medical appointment until after a vacation. d. An adult who was sexually abused as a child is unable to remember the incident 49) A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority? a. High fever b. Urinary hesitancy c. Insomnia d. Headache 50) A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder. Which of the following outcomes should the nurse include in the care plan? a. The client recognizes the importance of others b. The client conforms to social norms regarding clothing choices c. The client reduces self-dramatization d. The client treats others with respect 51) A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Negotiate with the client how much weight she should gain each week. b. Decrease the client’s daily intake of fiber c. Weight the client weekly for the first month d. Notify the client about designated time for meals 52) A client is fearful of driving and enters a behavioral therapy program to help him overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar street without experience a panic attack. The nurse should recognize that to continue positive results, the client should participate in which of the following? a. Therapist modeling b. Positive reinforcement c. Frequent practice d. Biofeedback 53) A nurse in the emergency department is counseling a client who reports experiencing intimate partner violence. Which of the following actions should the nurse take? a. Request permission from the client to take photographs of the injuries b. Offer to help the client escape form the partner the next time violence occurs c. Determine what the client did to trigger the violent incident d. Tell the client that staying with the partner shows a lack of judgment 54) A nurse is caring for a client who has prescription for phenelzine. The nurse should instruct the client to avoid which of the following over-the-counter medications? a. Ranitidine b. Pseudoephedrine c. Ibuprofen d. Docusate sodium 55) A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take? a. Avoid asking direct questions about the client’s experience b. Convey sympathy for the client’s experience c. Tell her client her experience is not real d. Focus the client on reality-based activities 56) A nurse is caring for a client who has just returned to the unit after receiving an electroconvulsive therapy treatment. Which of the following assessments is the nurse’s priority? a. First voiding b. Short-term memory c. Presence of gag reflex d. Return of bowel sounds 57) A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an inappropriate comment. Which of the following responses should the nurse make? a. “I think you should ignore the comment” b. “You sound upset about today’s session” c. “Why do you think that he said that to you?” d. “I agree that the comment was inappropriate” 58) A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? a. Hypotension b. Insomnia c. Bradycardia d. Diminished reflexes 59) A nurse is teaching a client who has bipolar disorder and a new prescription for lithium carbonate. Which of the following statements by the client indicates an understanding of the teaching? a. “I should drink at least 6 liters of water per day” b. “I should be on a low-sodium diet” c. “I will call my doctor if I have diarrhea” d. “I will see my doctor to check my lithium levels annually” 60) A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the following needs should the nurse collaborate with a clinical psychologist? a. The client needs a prescription for medication to promote nighttime sleep while in the facility b. The client needs to find a place to live after discharge c. The client needs to begin a group therapy program prior to discharge d. The client needs to relearn how to perform skill that require fine motor coordination 61) A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000/mm3 c. Urine pH 5.6 d. RBC 4.7/mm3 62) A nurse is teaching the caregiver of a client who has advanced Alzheimer’s disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching? a. I will ensure the bedroom is dark while he is sleeping at night b. I will place a sliding bolt lock just above the doorknob c. I will notify law enforcement within 2 hours if he cannot be found d. I will give his most recent photo to the police 63) A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid foods with tyramine to prevent which of the following? a. Hypertensive crisis b. Cardiac toxicity c. Serotonin Syndrome d. Urinary retention 64) A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following findings indicates the need for hospitalization? a. Potassium 3.8mEq/L b. Heart Rate 56/min c. Temperature 35.6C (96.1F) d. Weight 10% below ideal weight 65) A nurse us obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment finding in the client’s history should the nurse report to the provider? a. Hepatitis B Infection b. Hypothyroidism c. Knee arthroplasty 1 month ago d. Recent head injury 66) A nurse is providing crisis intervention for a client who was involved in a violent mass causality situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. help the client focus on a wide variety of topics regarding the crisis b. identify the client’s usual coping style c. tell the client that his life will soon return to normal d. encourage the client to display anger toward the cause of the crisis 67) A nurse in the community health facility is interviewing a client who recently lost his job. The client states “I was fired because my boss doesn’t like me” Which of the following defense mechanisms is the client displaying? a. Rationalization b. Displacement c. Dissociation Mental Health The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the ability to eat without assistance. Clients who have Alzheimer’s disease maintain this ability until Stage 7. b. The client independently manages personal finances. The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty performing complex tasks, such as managing personal finances. c. The client has bladder incontinence. The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6. d. The client is able to identify the names of family members. The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6. 3. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in the room is being recorded." Which of the following responses should the nurse make? a. "What we say is not being recorded." The nurse should avoid negating the client’s beliefs about the delusion. This response can promote a defensive client response and interfere with the development of trust in the nurse-client relationship. b. "Let's ignore the voices and talk about something else." The nurse should ask the client directly about what the voices are saying to determine if there is a safety risk. The nurse should also avoid validating that the voices are real, which promotes the client’s beliefs about the delusion. c. "That must be very frightening." The nurse should respond to the client’s delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship. d. "Why do you think the TV is a two-way radio?" The nurse should avoid asking the client a "why" question, which promotes a defensive client response. 4. A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? a. Practicing problem-solving skills The nurse should encourage the client to practice problem-solving skills during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. b. Understanding of medication regimen The nurse should ensure that the client understands the medication regimen during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. c. Identifying indications of relapse The nurse should teach the client to recognize indications of relapse during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. d. Maintaining adequate hydration The nurse should identify that the priority goal is to prevent physical exhaustion, maintain health, and meet nutritional and rest needs during the acute phase of the client’s manic episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels of priority when planning care for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow’s hierarchy of needs priority-setting framework the nurse should review physiological needs first. The nurse should then address the client’s needs by following the remaining four hierarchical levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow’s hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. 5. A nurse is preparing to administer benzodiazepine to a client with Generalized Anxiety Disorder. The nurse should tell the client to expect with of the following adverse reactions? a. Tinnitus Tinnitus is not an adverse effect of benzodiazepines. b. Bradycardia Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines. c. Halitosis Halitosis is not an adverse effect of benzodiazepines. d. Sedation The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines because of the CNS depression effects. 6. A nurse in a mental health unit is planning care for a client who is receiving treatment for self- inflicted injuries. The nurse should identify which of the following interventions as the priority when planning care for this client? a. Promoting and maintaining client safety The nurse should recognize that the client who has self-inflicted injuries is at risk for further self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply the safety and risk reduction priority-setting framework when planning care for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. b. Discussing reasons for the client's behavior The nurse should communicate with the client to discuss reasons for the client’s behavior; however, there is another action that is the priority. c. Assisting the client to recognize feelings The nurse should assist the client to recognize feelings; however, there is another action that is the priority. d. Teaching the client alternative coping strategies The nurse should teach the client alternative coping strategies; however, there is another action that is the priority. 7. A nurse is providing teaching to a client who has a new prescription for disulfiram for management of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to avoid? a. Peppermint candy It is not necessary for the client to avoid peppermint while taking disulfiram. b. Pure vanilla extract The nurse should instruct the client to avoid alcohol and alcohol-containing substances, such as pure vanilla extract, while taking disulfiram. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension. c. Salt Though certain medications require a reduction in sodium intake, it is not necessary for the client to avoid salt while taking disulfiram. d. Chocolate Though certain medications require a reduction in caffeine-containing substances such as chocolate, it is not necessary for the client to avoid chocolate while taking disulfiram. 8. A nurse is planning care for a client with a physical dependence of Alprazolam and must discontinue the medication. Which of the following should the nurse include in the plan? a. Taper the medication gradually over several weeks. The nurse should plan to taper the dosage of alprazolam gradually over several weeks, possibly months. This gradual reduction in dosage reduces the manifestations of withdrawal. b. Encourage participation in stimulating physical activity. The nurse should provide the client with a calm, low-stimulation environment to decrease the anxiety and physical manifestations that can result from alprazolam withdrawal. c. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication. The nurse should plan to monitor the client for at least 3 weeks following discontinuation of the medication for a return of anxiety manifestations. d. Implement restraints and seclusion as needed. It is not necessary to restrain or seclude the client during withdrawal from alprazolam. Restraints are considered restrictive, and the nurse should work to promote the least restrictive environment. 9. A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. the client tells the nurse “I have not had a drink for 6 hours.” Which findings should the nurse expect during alcohol withdrawals. a. Low body temperature The nurse should expect the client who is experiencing alcohol withdrawal to have an elevated temperature. b. Insomnia The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia and restlessness. c. Muscle flaccidity The nurse should expect the client who is experiencing alcohol withdrawal to have muscle tremors. d. Bradycardia The nurse should expect the client who is experiencing alcohol withdrawal to have tachycardia. 10. A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care? a. Buprenorphine The nurse should expect to administer buprenorphine to a client during opiate detoxification. b. Diazepam The nurse should expect to administer diazepam to a client during alcohol detoxification. Anti-anxiety agents, such as chlordiazepoxide and diazepam, are long-acting CNS depressants that are used to minimize the manifestations of alcohol withdrawal. c. Varenicline The nurse should expect to administer varenicline to a client who has nicotine use disorder. d. Rimonabant The nurse should expect to administer rimonabant to a client who has nicotine use disorder. 11. A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's. The nurse should conclude that the members of the group need further teaching when she identifies the following as manifestations of Alzheimer Disease. a. Impaired judgment The nurse should identify impaired judgment as a common manifestation associated with Alzheimer Disease. b. Sudden confusion The nurse should clarify that the client who has Alzheimer’s disease is expected to exhibit confusion that develops slowly over a period of months. Clients who have delirium exhibit sudden confusion. c. Personality change The nurse should identify that clients who have Alzheimer’s disease are expected to exhibit changes in personality as the disease progresses. d. Remote memory loss The nurse should identify recent and remote memory loss as common manifestations associated with Alzheimer’s disease. 12. A nurse is providing teaching to a client with Generalized Anxiety Disorder and a new prescription for Buspirone. The nurse should inform the client that which of the following manifestations is a common adverse effect of this medication? a. Confusion Confusion is not an adverse effect of buspirone, though the client might experience decreased concentration and headache. b. Bradycardia Tachycardia and palpitations, not bradycardia, are possible adverse effects of buspirone. c. Dizziness The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined. d. Insomnia Drowsiness, not insomnia, is an adverse effect of buspirone. 13. A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse should identify that it is safe to administer which of the following medications while the client is taking lithium? a. Ibuprofen Ibuprofen is not safe to administer to a client who is taking lithium because it can cause increased kidney absorption of lithium, which can lead to lithium toxicity. b. Haloperidol Haloperidol is not safe to administer to a client who is taking lithium because the combination of these medications increases the client’s risk for extrapyramidal adverse effects and tardive dyskinesia. c. Valproic acid Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for the nurse to administer both of these medications to the client. d. Hydrochlorothiazide Hydrochlorothiazide is not safe to administer to a client who is taking lithium because it promotes sodium loss, which can lead to lithium toxicity. 14. A nurse in the emergency department is caring for a toddler with a fractured arm. which of the following finding should the nurse suspect as possible abuse? a. The parent provides a history that is inconsistent with the child's injury. The nurse should suspect possible abuse when the child’s injury conflicts with the history of the injury that is reported by his parent. b. The child is brought to the emergency department immediately following the injury. The nurse should suspect possible abuse when there is a delay in seeking medical care following an injury. c. The parent requests to remain present with the child throughout treatment of the injury. The nurse should suspect possible abuse when the parent leaves the treatment area or facility after bringing the child in for treatment of an injury. d. The child clings to the parent when the nurse begins to assess the injury. The nurse should suspect possible abuse if the child displays fear of the parent. 15. A nurse is evaluating a care plan for a client who has an Antisocial Personality Disorder. Which of the following client actions indicates he is making progress in treatments? (Select All That Apply) a. Assisting another client who has depression to fill out a menu. Clients who have antisocial personality disorder tend to lack empathy for others and often display an inability to connect with others. Assisting another client indicates the client’s willingness to help and connect with others and demonstrates to the nurse his progress with treatment. b. Nominating himself to chair the client government meeting. Clients who have antisocial personality disorder tend to see themselves as superior to others. Providing a self-nomination for chairperson status places him in a position of power over others; therefore, this behavior does not indicate progress with the treatment. c. Requesting a weekend pass to go home. Clients who have antisocial personality disorder tend to disregard rules and have a lack of respect for authority. Requesting a weekend pass indicates the client’s willingness to follow unit rules and demonstrates to the nurse his progress with the treatment. d. Serving as the judge for a unit talent show. Clients who have antisocial personality disorder tend to see themselves as superior to others. Serving as a judge places the client in a position of power over others; therefore, this behavior does not indicate progress with the treatment. e. Informing the nurse that the staff provides excellent care to clients. Clients who have antisocial personality disorder often use flattery as a form of manipulation to promote personal gain; therefore, providing a compliment to the nursing staff does not indicate progress with the treatment. 16. A nurse is providing teaching to a client who is to start taking valproic acid. Which of the following instructions should the nurse include? a. "You should expect the provider to gradually decrease your dosage of valproic acid." The nurse should inform the client that the provider will initially prescribe a small dose, and then gradually increase the dose until a maintenance dosage is achieved. b. "You should take aspirin for pain you have while taking valproic acid." The nurse should instruct the client to avoid aspirin while taking valproic acid because of the increased risk of spontaneous bleeding. c. "You should undergo thyroid function tests every 6 months while taking valproic acid." The nurse should identify that hypothyroidism is an adverse effect of lithium rather than valproic acid. d. "You should have your liver function levels monitored regularly while taking valproic acid" The nurse should inform the client of the need to regularly monitor liver function levels due to the risk for hepatotoxicity while taking valproic acid. It is recommended to obtain baseline levels and then repeat every 2 months during the first 6 months of therapy. 17. A nurse is teaching a client who has Agoraphobia about Systematic Desensitization. Which of the following comments should the nurse include in the teaching? a. "You will watch from a secure location as your therapist goes to public spaces." The nurse should recognize that encouraging the client to watch as the therapist acts as a role model in anxiety-provoking situations is an example of modeling, not systematic desensitization. b. "You will start your therapy by staying in a public space until your anxiety decreases." The nurse should recognize that sudden exposure of the client to the undesirable stimulus is an example of flooding, not systematic desensitization. c. "You will be instructed to say 'Stop!' out loud when you become anxious in public spaces." The nurse should recognize that saying "Stop!" to interrupt a negative thought is an example of thought stopping, not systematic desensitization. d. "You will slowly be exposed to increasing levels of public spaces." The nurse should inform the client that, using systematic desensitization, she will be gradually exposed to the feared situation under controlled conditions until she learns to overcome the anxious response. 18. A nurse is planning a staff education session about the administration of antidepressant medications to older adult clients. Which of the following information should the nurse include in the teaching? a. Older adult clients require a lower initial dose of antidepressant medication than adult clients. The nurse should recognize that older adult clients are recommended to start at half the adult dose for antidepressant medications. This is due to altered rates of absorption and the increased risk for adverse effects. b. Older adult clients should not receive antidepressant medication. The nurse should identify that antidepressant medications are commonly prescribed for older adult clients; however, adjustments are needed due to the clients' altered rates of absorption. c. Older adult clients achieve the therapeutic effects of antidepressant medications more quickly than adult clients. The nurse should identify that older adult clients have a decreased rate of absorption, distribution, and metabolism, resulting in a delay in achieving therapeutic effects. It can take about 1 month of treatment for the older adult client to achieve therapeutic effects. d. Older adult clients have a decreased risk for adverse effects from antidepressant medication. The nurse should identify that older adult clients have an increased risk for adverse effects due to a decreased rate of excretion. 19. A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? a. Postpartum depression The nurse should recognize that memantine, an N-methyl-D-aspartate (NMDA) receptor agonist, is not indicated for the treatment of depression. b. Schizophrenia The nurse should recognize that memantine, an NMDA receptor agonist, is not indicated for the treatment of schizophrenia. c. Obesity The nurse should recognize that memantine, an NMDA receptor agonist, is not indicated for the treatment of obesity. d. Severe Alzheimer's disease The nurse should expect a prescription for memantine for a client who has moderate to severe Alzheimer’s disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and to improve cognitive function. 20. A nurse is assessing a client who has Binge-Eating Disorder. Which of the following findings should the nurse expect? a. Amenorrhea Clients who have binge-eating disorder often have an increased BMI; therefore, amenorrhea resulting from a low body weight is not expected. b. Abdominal pain The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food. c. Restricted caloric intake Clients who have binge-eating disorder often have an increased BMI resulting from eating excessive volumes of food. d. Frequent use of laxatives Clients who have binge-eating disorder have repeated episodes of binging without the use of compensatory behaviors, such as the use of laxatives. 21. A nurse on an acute care unit is providing postoperative care for an elderly patient who developed Delirium. Which of the following actions should the nurse take? a. Request a prescription for an antianxiety medication. The nurse should request a prescription for an antianxiety medication for a client who develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety and agitation. b. Provide the client with a stimulating activity prior to bedtime. The nurse should maintain a low-stimulation environment for the client to decrease disorientation due to overstimulation. c. Keep the lights in the client's room dim at night. The nurse should keep the client’s room well-lit. Adequate lighting can help her to remain oriented to place upon waking at night and will provide for safety if she becomes ambulatory. d. Encourage the client to make decisions about her daily routine. The nurse should provide the client with a consistent routine and limit her need to make decisions. These actions will decrease disorientation and anxiety. 22. A nurse assessing a client who has Conduct Disorder. Which of the following findings should the nurse expect? a. Fearfulness of authority figures Clients who have conduct disorder exhibit a lack of respect for authority figures and might attempt to initiate a fight with or intimidate others. b. Flat affect Clients who have conduct disorder are easily angered and do not have a flat affect. c. Preoccupation with enforcing rules Clients who have conduct disorder exhibit a lack of respect for rules. d. Aggressive behavior toward others The nurse should expect the client who has conduct disorder to exhibit aggression toward others and impulsively violate others' rights. 23. A nurse in an acute care facility is leading a staff discussion about the legal implications of involuntary admissions. Which of the following should the nurse include? a. A client who is involuntarily admitted must take prescribed medications. Clients who are involuntarily admitted retain the legal right to refuse medications. b. An involuntary admission of a client is limited to 2 weeks. Clients who are involuntarily admitted might be required to remain in the facility for up to 60 days. After this time a legal review of the case is required to determine if continued involuntary treatment is required. c. A client who is involuntarily admitted can leave the facility against medical advice. Clients who are involuntarily admitted retain certain rights; however, they are unable to leave the health care facility against medical advice. If a client who is involuntarily admitted feels that the admission is unjustified, the client can file a legal petition requesting a review of the admission. d. An involuntary admission is justified if the client is a danger to others. A client who is a danger to others or to himself qualifies for an involuntary admission. The inability to meet basic needs due to the need for mental health treatment is also a justification for an involuntary admission. 24. A nurse is caring for a client who has Schizophrenia. The nurse notices that the client is pacing up and down the hall very rapidly and muttering in an angry manner. Which of the following actions should the nurse take first? a. Apply mechanical restraints to the client. The nurse might have to place the client in restraints to prevent harm to others and allow the client to calm down; however, the nurse should use a less restrictive intervention first. b. Administer PRN haloperidol IM to the client. The nurse might have to administer PRN haloperidol to calm the client; however, the nurse should use a less restrictive intervention first. c. Approach the client in a nonthreatening manner. The first action the nurse should take is to approach the client calmly, in a nonthreatening manner, to create a nonthreatening environment. The nurse should apply the least restrictive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. d. Place the client in seclusion. The nurse might have to place the client in seclusion to prevent harm to others and allow the client to calm down; however, the nurse should use a less restrictive intervention first. 25. A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. For which of the following findings should the nurse question the provider's prescriptions? a. A skeletal muscle injury Benzodiazepines have muscle relaxant properties and can relieve muscle spasms; therefore, a skeletal muscle injury is not a contraindication for receiving benzodiazepines. b. History of status epilepticus Benzodiazepines can raise the seizure threshold and prevent seizures; therefore, a history of status epilepticus is not a contraindication for receiving benzodiazepines. c. Hypotension The nurse should question the provider’s prescription for a benzodiazepine for a client who has hypotension. Benzodiazepines can cause severe hypotension and increase the client’s risk for cardiac arrest. d. Insomnia Benzodiazepines induce sleep for clients who have a sleep disorder; therefore, insomnia is not a contraindication for receiving benzodiazepines. 26. A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following instructions should the nurse include in the teaching? a. "Ignore your child's attention-seeking behaviors that are not dangerous." The nurse should instruct the parents about the use of planned ignoring. This technique ignores attention-seeking behaviors that are not dangerous to the child or others. If the child learns that the behavior will not elicit the desired response, then the behavior should decrease. b. "Administer ADHD medications within 30 minutes of your child's bedtime." The nurse should instruct the parents to administer medications in the morning to decrease insomnia, which is a common adverse effect of ADHD medications. c. "Continue with an activity as planned even if your child becomes frustrated." The nurse should instruct the parents about the use of restructuring. This technique adjusts or changes an activity based on the child’s level of frustration. d. "Expect your child to gain weight after starting ADHD medications." The nurse should instruct the parents that a decreased appetite and weight loss are common adverse effects of ADHD medications. 27. The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings should the nurse expect? a. Poor personal hygiene habits The nurse should not expect the client who has anorexia nervosa to have poor personal hygiene habits. Clients who have anorexia nervosa often exhibit compulsive behaviors, such as frequent hand washing, and are preoccupied with their appearance. b. Strenuous exercise regimen The nurse should expect the client who has anorexia nervosa to report a strenuous exercise regimen. The client might participate in excessive physical activity due to the perceived need to burn calories and lose weight. c. Grandiose behaviors The nurse should expect clients who have anorexia nervosa to have poor self-esteem and negative feelings about themselves. d. Intense fear of death The nurse should expect the client who has anorexia nervosa to have an intense fear of gaining weight. Clients who have anorexia nervosa exhibit behaviors that have negative health consequences in order to prevent weight gain. 28. A nurse is caring for a client who has depression, the clients states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? a. "Attending group therapy, even if you're tired, is an important part of your treatment." The nurse provides a therapeutic response by giving the client information to make an informed decision. Group therapy is beneficial to the client who has depression by promoting peer support and reducing social isolation. b. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." The nurse should recognize that a lack of energy is expected for a client who has depression. There is no indication that the client will have more energy for group therapy in the future. The nurse should also respect the client’s autonomy and avoid giving a directive about required participation. c. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." The nurse should avoid minimizing the client’s feelings by making a generalization about her status in relation to others. d. "I agree with your decision to wait for participation in group therapy until you begin to feel better." The nurse should avoid giving approval to the client’s decision, which promotes the need for her to please the nurse. The nurse should also encourage her to participate in group therapy to promote improvement of her depression. 29. A nurse is performing an admission assessment for a client who has restricting type Anorexia Nervosa. The nurse should expect which of the following findings? a. Decreased caloric intake The nurse should expect the client who has restricting type anorexia nervosa to have a restricted and decreased caloric intake due to the client’s intense fear of weight gain. b. Recurrent binging Recurrent binging is an expected finding of binge-eating/purging type anorexia nervosa. Clients who have restricting type anorexia nervosa are not expected to exhibit bulimic manifestations, such as binge eating. c. Compensatory vomiting Compensatory vomiting is an expected finding of binge-eating/purging type anorexia nervosa. Clients who have restricting type anorexia nervosa are not expected to exhibit bulimic manifestations, such as compensatory vomiting. d. Loss of appetite Loss of appetite is not an expected finding of a client who has anorexia nervosa. Clients who have restrictive type anorexia nervosa maintain an appetite; however, they have inadequate intake due to fear of gaining weight. 30. A nurse in a substance abuse treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer Methadone for a client who has a substance use disorder for which of the following addictions? a. Amphetamines The nurse should recognize that the administration of methadone is not indicated for the treatment of amphetamine use disorder. b. Opiates The nurse should recognize that the administration of methadone is indicated for the treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of opiate withdrawal. c. Barbiturates The nurse should recognize that the administration of methadone is not indicated for the treatment of barbiturate use disorder. d. Hallucinogenics The nurse should recognize that the administration of methadone is not indicated for the treatment of hallucinogen use disorder. 31. A nurse is caring for a client who has just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect? a. Bargaining The nurse should expect the client to exhibit bargaining during the grief process; however, there is another response that is expected first. b. Depression The nurse should expect the client to exhibit depression during the grief process; however, there is another response that is expected first. c. Denial The nurse should expect the client to initially deny the reality of the diagnosis. This is a protective reaction that serves to protect the client from psychological pain. d. Anger The nurse should expect the client to exhibit anger during the grief process; however, there is another response that is expected first. 32. A nurse is caring for a client with Alzheimer Disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? a. Talk to the client from two arm-lengths away. The nurse should talk calmly and quietly to the client to decrease her agitation. The nurse should remain one to two arm-lengths away to provide her with a sense of personal space and maintain safety if she becomes aggressive. b. Obtain assistance to restrain the client for safety. The nurse should identify that the client’s refusal of care is not a justification for restraints. The nurse should apply restraints only if her behavior becomes a threat to her safety or the safety of others. c. Firmly state to the client that morning care will be performed. The nurse should recognize that the client has a right to refuse care. Telling her that care will be performed, despite refusal, can increase her anxiety and agitation. d. Call the provider to request a prescription for an antipsychotic medication. The nurse should recognize that antipsychotic medications are used only with extreme caution due to the increased risk of death for clients who have Alzheimer’s disease. Antipsychotic medications are not indicated for the treatment of agitation. 33. A nurse is assessing a client who takes Phenelzine for the treatment of Depression. Which of the following finding should the nurse report to the provider? a. Elevated blood pressure The nurse should identify that the greatest risk to the client is an elevated blood pressure, which increases his risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction priority-setting framework when assessing this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. b. Weight gain The nurse should identify weight gain as a common adverse effect of an MAOI, such as phenelzine. The nurse should report the adverse effect to the provider; however, there is another finding that is a greater risk to the client than weight gain. c. Muscle twitching The nurse should identify muscle twitching as a common adverse effect of an MAOI, such as phenelzine. The nurse should report the adverse effect to the provider; however, there is another finding that is a greater risk to the client than muscle twitching. d. 2+ peripheral edema The nurse should identify peripheral edema as a common adverse effect of an MAOI, such as phenelzine. The nurse should report the adverse effect to the provider; however, there is another finding that is a greater risk to the client than peripheral edema. 34. A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? a. Flat affect The nurse should expect the client who has rape-trauma syndrome to experience mood swings and intense emotions. b. Refusal to accept help from others The nurse should expect the client who has rape-trauma syndrome to exhibit dependence toward others. c. Report of intense guilt The nurse should expect the client who has rape-trauma syndrome to experience guilt about the sexual assault. These feelings of guilt can delay the healing process and produce a sustained and maladaptive response. d. Denial of the sexual assault The nurse should expect a client to have denial immediately following a sexual assault; however, this is not a characteristic of rape-trauma syndrome. 35. A nurse in interviewing an older adult client about possible anger abuse by her caregiver. Which of the following techniques should the nurse use? a. Avoid directly asking the client if she has been abused. The nurse should ask the client directly about possible abuse to identify the client’s physical, emotional, and safety needs. b. Use a confrontational approach. The nurse should avoid a confrontational approach, which can raise the client’s defensive barriers and potentially block further communication. c. Maintain a nonjudgmental tone. The nurse should use a nonjudgmental tone to promote trust and communication. d. Avoid being in the room alone with the client. The nurse should conduct the interview in private to provide a calm and safe environment. 36. A nurse is providing teaching for a family of a client who has Alzheimer Disease about Donepezil. Which of the following statements should the nurse include in the teaching? a. "Donepezil can improve cognitive functioning during the earlier stages of the disease." The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe Alzheimer’s disease. Although donepezil does not prevent the progression of Alzheimer’s disease, it is intended to prolong the client's ability to function in the early stages of the disease. b. "Donepezil cures the disease process if it is started upon first recognition of dementia." The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe Alzheimer’s disease; however, donepezil does not prevent the progression of Alzheimer’s disease. c. "Donepezil provides long-term reversal of memory loss in the last phase of the disease." The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe Alzheimer’s disease. Though donepezil can provide mild improvements in memory, it does not reverse memory loss. Improvements in the client’s memory are usually short-term. d. "Donepezil accelerates the breakdown of acetylcholine within the client's brain." The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe Alzheimer’s disease. Donepezil works by preventing the breakdown of acetylcholine within the client’s brain, increasing its availability at cholinergic synapses. 37. A nurse is obtaining a client's medical history prior to scheduling them for ECT. Which of the following findings should the nurse identify as a potential complication for the procedure? a. Severe depression A client can receive ECT for treatment of severe depression. b. Cardiac arrhythmia A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that the greatest risk for death due to ECT is related to cardiac complications. c. Bipolar disorder A client can receive ECT for treatment of bipolar disorder. d. Parkinson's disease A client can receive ECT for treatment of Parkinson's disease. 38. A nurse is planning care for a client who had Bipolar Disorder and is experiencing a Manic Episode. Which of the following interventions should the nurse include in a plan of care? a. Discourage the client from taking naps during the day. The nurse should encourage the client to take naps and frequent rest periods during the day to avoid physical exhaustion due to mania. b. Allow the client to choose which clothing to wear each day. The nurse should closely supervise the client’s choice of clothing to maintain her dignity and promote positive self-esteem during a manic episode. c. Encourage the client to participate in group therapy. The nurse should encourage one-on-one therapy during the manic phase. Group therapy can cause anxiety and agitation in the client. d. Provide the client frequently with high-calorie finger-foods. The nurse should provide the client with frequent, high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client’s intake by making it easier to eat when mania makes it difficult for her to sit down and concentrate on a meal. 39. A nurse in an acute mental health facility is caring for a client who is experiencing an Acute Manic Episode. Which of the following actions is the nurse's priority? a. Maintain the client's contact with her family. The nurse should assist all acute care clients in maintaining contact with family during treatment; however, there is another action that is the priority. b. Discourage the client's use of vulgar language. The nurse should discourage behaviors that disrupt the therapeutic milieu; however, there is another action that is the priority. c. Protect the client from impulsive behavior. The nurse should protect the client who is manic from impulsive behavior that puts the client at risk for self-harm. The nurse should apply the safety and risk reduction priority- setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. d. Redirect excessive energy to creative tasks. The nurse should redirect the client’s energy into a calming and constructive activity; however, there is another action that is the priority. 40. A nurse in an acute mental health facility is planning care for a client who has obsessive- compulsive disorder (OCD). Which of the following actions should the nurse include in the plan? a. Encourage the client to focus on personal hygiene. Clients who have OCD are often obsessive about personal hygiene and might perform ritualistic behaviors related to handwashing and grooming. The nurse should plan interventions to limit and control these obsessive thoughts. b. Limit the hours the client sleeps each day. Clients who have OCD often have difficulty sleeping due to obsessive thoughts and ritualistic behaviors. The nurse should plan interventions to promote sleep. c. Instruct the client to practice thought stopping. The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out loud, the client can learn to interrupt obsessive thoughts. d. Make negative statements about the client's behavior. Clients who have OCD often feel shame and humiliation about their obsessive thoughts and ritualistic behavior. The nurse should plan interventions to decrease feelings of shame and increase feelings of self-worth. 41. A nurse is caring for a client who has alcohol use disorder.Following alcohol withdrawal, which of the following medications should the nurse expect to administer to the client during maintenance? a. Methadone The nurse should expect to administer methadone to the client who has opioid withdrawal. b. Disulfiram The nurse should expect to administer disulfiram as a deterrent to prevent future use of alcohol. The nurse must ensure that the client has not had any alcohol intake for at least 12 hr prior to administration. c. Chlordiazepoxide The nurse should expect to administer chlordiazepoxide during alcohol withdrawal. Chloridiazepoxide is not a medication used to help with maintenance. d. Naloxone The nurse should expect to administer naloxone to the client who is experiencing a narcotic overdose. 42. A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse he isn't going to attend any further sessions and states, "I don't have time for all this talking." Which of the following responses should the nurse make? a. "It must be difficult for you to talk about family problems." The nurse’s response indicates empathy for the client’s feelings and is an example of the therapeutic communication technique of verbalizing what the client implied. With this technique, the nurse helps him focus on the actual reason for not wanting to continue family therapy. b. "You should continue attending the family counseling sessions until the therapist tells you to stop." The nurse’s response is an example of the nurse giving advice, which is nontherapeutic and a possible block to further communication. c. "If you continue to go to family counseling, I'm sure you'll be able to resolve your family problems soon." The nurse’s response is an example of false reassurance. The client’s continued participation is not an indication that problems will be resolved. d. "I think you need to continue family therapy if your partner and children want to receive further counseling." The nurse’s response is an example of the nurse giving advice, which is nontherapeutic and a possible block to further communication. 43. A nurse in an acute substance is assessing a client who received treatment in the Emergency Department for a Heroin Overdose. Which of the following findings should the nurse anticipate during Heroin Withdrawal? a. Excessive sleeping The nurse should expect the client to have insomnia during heroin withdrawal. b. Muscle aches The nurse should expect the client to have muscle aches during heroin withdrawal. The nurse should expect this and other manifestations of withdrawal to begin within 6 to 8 hr following the last dose of heroin. c. Pupillary constriction The nurse should expect the client to have pupillary dilation during heroin withdrawal. d. Absent bowel sounds The nurse should expect the client to have diarrhea during heroin withdrawal. 44. A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect? a. Low blood pressure The nurse should expect a client who has cocaine intoxication to have an elevated blood pressure. b. Dilated pupils Dilated pupils are associated with the use of cocaine. c. Conjunctival redness The nurse should expect a client who has cannabis intoxication to have conjunctival redness. d. Decreased body temperature The nurse should expect a client who has cocaine intoxication to have an elevated body temperature. 45. A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is admitted under court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display? a. Relief about finally receiving care for a problem for which he was previously afraid to ask for help A client who has antisocial personality disorder exhibits a pattern of irresponsible behavior that lacks morals and ethics and brings the client into conflict with society. The client views this behavior as justified and does not perceive the need for help. b. Anger with the nursing staff for hospitalizing him against his will. A client who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation goes against his will or desires. c. Withdrawal from others due to shame over his recent actions Clients with antisocial behavior do not view their own behavior objectively and rarely experience any anxiety or guilt over their actions. d. Remorse for stealing and destroying the car Clients who have antisocial behavior usually display a sense of entitlement and rarely express any remorse for their illegal or unethical actions. 46. A nurse is developing a plan of care with a client who has Anorexia Nervosa. The nurse should identify that which of the following actions is contraindicated for this client? a. Explaining that tube feedings are necessary if the client refuses oral intake The nurse should inform the client that he might require tube feedings to provide adequate nutritional intake if oral intake is inadequate. This intervention is not intended to be punitive but to ensure the client’s safety. b. Weighing the client each day prior to any oral intake The nurse should weigh the client each day prior to any oral intake to obtain accurate data and to monitor his progress toward weight gain goals. c. Permitting the client to spend some quiet time alone after each meal The nurse should directly observe the client for a minimum of 1 hr following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for his plan of care. d. Refraining from commenting about the client's eating during meal times The nurse should encourage conversation during meals to promote a pleasurable eating environment; however, the nurse should avoid the topics of eating and food, which can increase the client’s level of anxiety. 47. A nurse in the Emergency Department is assessing a client who has Heroin Intoxication. Which of the following findings should the nurse expect? a. Seizure activity Heroin is an opioid, which can result in impaired coordination rather than seizure activity. b. Respiratory depression Heroin is an opioid; therefore, the nurse should expect the client who has heroin intoxication to exhibit respiratory depression. c. Hypersensitivity to pain Heroin is an opioid, which can result in pain reduction rather than a hypersensitivity to pain. d. Increased mental alertness Heroin is an opioid, which can result in drowsiness and sedation rather than increased mental alertness. 48. A nurse is caring for a client who has Alzheimer Disease and a new prescription for Donepezil. Which of the following actions should the nurse take? a. Monitor the client's liver function while taking this medication. The nurse should monitor the liver function for a client who is taking the cholinesterase inhibitor tacrine; however, donepezil is a medication in this category that is not hepatotoxic. b. Increase the dosage of this medication every 72 hr. The nurse should expect the provider to gradually increase the client’s dosage until a therapeutic effect is achieved; however, an increase is not expected until the client has been taking the medication for 4 to 6 weeks. c. Offer the client a PRN NSAID while taking this medication. The nurse should inform the client of the risk for gastrointestinal bleeding while taking this medication. Taking donepezil concurrently with an NSAID increases this risk. d. Administer the medication at bedtime. Donepezil is used to treat the manifestations of mild to moderate Alzheimer’s disease. The nurse should administer this medication at bedtime to reduce the risk for injury due to bradycardia and syncope. 49. A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? a. Continue to talk if the client does not provide an immediate verbal response. The nurse should allow the client additional time to respond. Clients who are severely withdrawn might take longer to comprehend what is being said and formulate a response. b. Use platitudes when talking with the client. d. Esophageal pain The nurse should expect the client who has esophagitis due to alcohol use to have esophageal pain. Gastrointestinal manifestations are not expected findings with Wernicke-Korsakoff syndrome. MENTAL HEALTH 3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self- denial. The nurse should recognize that these findings are associated with which of the following personality disorders? a. Dependent b. Paranoid c. Borderline d. Histrionic • A nurse is creating a plan of care of a client who has anorexia nervosa. Which of the following intervention should the nurse include in the plan? a. Weigh the client twice per day b. Prepare the client for electroconvulsive therapy c. Set a weight gain goal of 2.2kg (5lbs) per week d. Encourage the client to participate in family therapy • A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following finding should the nurse expect? a. Readily initiates conversation b. Enjoys imaginative play c. Strong relationship with sibling and peers d. Attachment to objects that spin • A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention. a. Secure the client’s valuable possessions b. Limit loud noises in the client’s environment c. Encourage the client to participate in structured solitary activities d. Provide high calorie snacks to the client • A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication. a. Blocks aldehyde dehydrogenase b. Prevents the anxiety of abstinence c. Reduces substance craving d. Decreases the likelihood of seizures • A nurse in an alcohol treatment facility is caring for a client who states “my job is so stressful that the only way I can come it is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms? a. Repression b. Rationalization c. Introjection d. Intellectualization • A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills? a. How does this situation affect your life? b. Do you see your current situation affecting your future? c. Can you describe how you are currently feeling? d. How have you dealt with similar situations in the past • Identify names of family members [Show More]

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