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Exam (elaborations)

ATI: RN 3.0 Mental Health 2 Questions with correct Answers

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ATI: RN 3.0 Mental Health 2 Questions with correct Answers A nurse is providing discharge teaching for a female client who has an anxiety disorder and a new prescription for lorazepam. Which of the following instructions should the nurse include in the teaching? "this med must be discontinued gradually" rapid withdrawal from lorazepam has been associated with manifestations of withdrawal, such as anxiousness, sleeplessness, and irritability. it is discontinued by gradually tapering if off over time to avoid any adverse responses. A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for several months. Which of the following levels should the nurse recognize as a therapeutic lithium level? 1.2mEq/L range: 1.0-1.5 Clients taking lithium should drink six to eight glasses of water day to maintain a normal state of hydration. A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? Impaired judgement. Impaired judgement occurs in clients who have dementia because they lose their ability to reason, think abstractly, and have rational thoughts. A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors should the nurse identify as increasing the client's risk for depression? The client is female. The nurse should identify female gender as a primary risk factor for depression. The incidence of depressive disorders is greater in women than in men by almost 2 to 1. A nurse is caring for a client who has obsessive-compulsive disorder. The client engages in repeated handwashing daily. Which of the following should the nurse recognize as the purpose of the client's behavior? Relieving anxiety. Ritualistic and compulsive behaviors, such as repeated hand washing, are associated with obsessive-compulsive disorder. The client has a strong urge to perform these acts in an attempt to reduce anxiety. Performing these acts only temporarily reduces the anxiety. A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse should identify that the client is exhibiting which of the following disorders? Agoraphobia Fear and avoidance of places where escape might be difficult A nurse is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective? the clients report techniques she uses to promote sleep A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. Which of the following actions should the nurse take first? Instruct the client to take slow, deep breaths. Apply the safety and risk reduction priority-setting framework. A nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy? demonstrating performance of hand hygiene as designated times. this action is an example of modeling, which is a behavioral intervention strategy that allows the client ot see the expected behaviors performed by the nurse. A nurse in a mental health clinic is assessing a client who has a history of mania. Which of the following findings indicates that the client is experiencing a relapse? Pressured speech This is an indication of relapse in a client who has mania. A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates that the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take? administer the med because it is within ranges A nurse is assessing< a client who has a psychotic disorder and a new prescription for haloperidol. The client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is the client likely experiencing? Akathisia. Akathisia is an extrapyramidal adverse effect characterized by the client's report of sense of inner restlessness and by observable behaviors such as pacing, rocking forward and backward in a chair, and constant foot tapping. A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? chicken nuggets, crackers, a cookie, cheese sticks provide him with high-calorie finger foods that can be carried and are relatively easy to manipulate. A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine The nurse should instruct the client that which of the following blood tests should be performed periodically? glucose at risk for abnormal glucose metabolism, can result diabetes mellitus. A nurse is assessing a client who has schizophrenia. The client states, "I need to get my gummamoshu from by my house." The nurse recognizes this statement as an example of which of the following? Neologism. The nurse should recognize the client's response as a neologism, an invented word which has no meaning to those around him. A nurse on an inpatient unit is assessing a client who has claustrophobia. The nurse determines the client's condition has improved when he can perform which of following tasks? ride in an elevator A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the client's provider immediately? Urinary retention. Urinary retention can lead to bladder infection and, ultimately, loss of bladder tone. The nurse should apply the safety and risk reduction priority-setting framework. An emergency room nurse is assessing a client who has an anxiety disorder. The client is flushed, perspiring profusely, and is experiencing palpitations. The client begins to scream, "I am going to die! This is it! I am having a heart attack!" The nurse should determine the client's level of anxiety to be which of the following Panic. This client's manifestations indicate the panic level of anxiety and indicate manifestations of a panic disorder. A school nurse is caring for an adolescent client who has a history of a depressive episode 1 year ago. He appears withdrawn from social activities and his school performance is declining. Which of the following actions should the nurse take first Conduct a suicide risk assessment. Safety and risk reduction priority-setting framework. A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make ? this medication is an anti-psychotic that controls symptoms of schizophrenia A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? Head ache Also: tachycardia, sweating, nausea, hand tremors, depression, irritability, vomiting A nurse is assessing a client who has been taking an antipsychotic medication for 6 years and the provider has started tapering off the dosage. The nurse should monitor the client for which of the following manifestations of tardive dyskinesia? Involuntary tongue protrusion Tardive dyskinesia begins with face and mouth and then leads to larger muscle groups A nurse is assessing a client who has been taking thioridazine for several days. The client reports hand tremors, drooling, and rigid extremities. Which of the following actions should the nurse take? Administer benztropine This client is experiencing extrapyramidal effects of thioridazine, which includes pseudoparkinsonism. Benztropine is a medication that counteracts these adverse effects. The nurse should notify the provider if extrapyramidal effects occur and obtain a prescription to alleviate the manifestations. A nurse is providing teaching to a client who has a new prescription for phenelzine. The nurse should teach the client that which of the following over-the-counter medications can cause a hypertensive crisis when taken concurrently with phenelzine? Pseudoephedrine: it interacts with MAOI's thus is contraindicated. This med is used to relieve nasal congestion caused by colds, allergy is also used to temporarily relieve sinus congestion and pressure. A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take when dealing with the client's ritualistic behaviors? Plan the pts schedule to allow time for ritualistic behaviors. The nurse should allot sufficient time for the client to perform rituals early in the treatment. this will help keep anxiety levels manageable and prevent the precipitation of panic anxiety. A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited the day before. Which of the following cognitive impairments is the client demonstrating? Confabulation is filing in gaps in memory by fabrication. the client unconsciously makes up response that are inaccurate to avoid the embarrassment of memory loss. A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment? physical needs first! maslow's hierarchy of needs, five levels of priority. the first level is physiological needs, the second level is safety and security; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. A nurse is caring for a client who has a severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take? Speak to the client in a calm voice. The initial goal for a client who is in a state of panic is to obtain relief. The nurse should stay with the client and speak in a calm manner. A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. Which of the following statements should the nurse make? "We will assist you in making decisions." Clients who have post-traumatic stress disorder experience flashbacks; therefore, this would not be necessary for a client who has generalized anxiety disorder. A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as, "Me, see, bee, tree." The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia? Clang association. The stringing and repeating of words together because of their rhyming sounds is called clang association. Clang association is a positive manifestation of schizophrenia.

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