RN MENTAL HEALTH ONLINE 2019 B NGN WITH RATIONALES

RN MENTAL HEALTH ONLINE 2019 B NGN WITH RATIONALES 1. A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? a. Identify signs of escalation of violence i. It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave. 2. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? a. Reduce environmental stimuli. i. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury. 3. A nurse is updating the POC for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? a. Identify the client's trigger foods. i. The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food. 4. A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements made by the client indicates acceptance of her illness? a. "I am going to order a wheelchair for when I'm unable to walk." i. The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral response of acceptance. 5. A nurse is reviewing the medication administration for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? a. Acute dystonia