ATI Mental Health 2020 B with NGN

A nurse is caring for 4 clients who are displaying the use of defense mechanisms. Which of the following clients should the nurse identify as using a maladaptive defense mechanism? A. A client with multiple sclerosis stops taking their medication and says their diagnosis is wrong. B. An adolescent client who has difficulty with reading and becomes a star athlete. C. A client admires a highschool principal who seperated two students who were having a fight. D. A client who has a gambling disorde - A. A client with multiple sclerosis stops taking their medication and says their diagnosis is wrong. Suppression is the blocking of thoughts or feelings that a client finds unacceptable. Denying the presence of an illness is a maladaptive use of a defense mechanism. A nurse is caring for a client who is taking lithium and reports presisant nausea and vomiting for 2 days. Which of the following lab values should the nurse report to the provider? A. Potassium 4.0 mEq/L B. Lithium 0.9 mEq/L C. BUN 12 mg/dL D. Sodium 132 mEq/L - D. Sodium 132 mEq/L The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider. A nurse is collecting data from a client who is taking valproic acid for the treatment of BPD. Which of the following findings is priority to report to the provider? A. Dizziness B. Weight gain C. Constipation D. Yellow sclerae - D. Yellow sclerae When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is yellow sclerae because of the risk for hepatotoxicity. A nurse is reinforcing teaching about foods that contain tyramine with a client who has a prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid? A. Fried chicken B. Oranges C. Smoked sausage D. Lentils - C. Smoked sausage Smoked sausages are high in tyramine. Clients who are prescribed monoamine oxidase inhibitors (MAOIs) should avoid food that contain tyramine because consuming them can cause a hypertensive crisis. A nurse is caring for a client who recently lost their child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? A. "Are there times when you feel more upset than others?" B. "Have you had any thoughts of harming yourself?" C. "What type of support system do you currently have?" D. "During difficult times in the past, what did you do to cope?" - B. "Have you had any thoughts of harming yourself?" The greatest risk to this client is self-injury due to suicide. Asking whether or not the client has plans to hurt themselves is the most important question for the nurse to ask at this time because a positive response can alert the nurse to the need for suicide precautions and intervention. A nurse on a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following statement indicates an understanding of the teaching? A. "The consent form should be written at a seventh-grade reading level." B. "If the consent form is signed, I can send a client for a procedure even if they have questions." C. "I should explain everything to the client about the procedure before the client signs the consent form." D. "The consent form should ha - D. "The consent form should have the name of the provider who is performing the procedure on the form." The consent form should include the name of the provider who will be performing the procedure. This should be present on the form before the client signs it. A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan? A. The client will participate in assertiveness training. B. The client will discuss feelings that cause hostility. C. The client will describe an activity they found enjoyable. D. The client will dress in a manner appropriate for the setting and temperature. - B. The client will discuss feelings that cause hostility. Clients who have antisocial personality disorder are frequently aggressive and are at risk for injuring themselves or others. A short-term goal for these clients should be to discuss feelings that precipitate aggression or hostility. A nurse is caring for a client who has depressive disorder and declines ECT despite the providers recommendation. Which of the following ethical principles is the nurse demonstrating by supporting the clients decision? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice - A. Autonomy The nurse is demonstrating the principle of autonomy by respecting and supporting the client's right to make decisions about their treatment. A nurse is participating in group therapy for clients who have major depressive disorder. Which of the following topics should the nurse include in the orientation phase of group therapy? A. Confidentiality B. Developing goals C. Problem solving D. Identifying the roles of group members - A. Confidentiality The nurse should establish the expectations of confidentiality during the orientation phase of group therapy. A nurse is collecting data from a client who has major depressive disorder and is taking phenelzine. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Weight gain B. Diarrhea C. Proteinuria D. Bleeding gums - A. Weight gain Weight gain, insomnia, and muscle cramps are adverse effects of phenelzine. A nurse in an inpatient mental health unit is supervising a group of clients in the unit's day room. The nurse fails to respond to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable? A. Battery B. Nonmaleficence C. Negligence D. Boundary violation - C. Negligence The nurse is liable for negligence by failing to respond to the client's escalating, aggressive behavior and prevent harm to others. A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and their own personal beliefs. After collecting data and identifying the problem, which of the following actions should the nurse take next? A. Discuss information about the dilemma with the client's provider. B. Determine the benefits and consequences of respecting the client's medical decisions. C. Reflect on the effect of ethical theories on the nurse's personal values. D. Develop a plan that bala - B. Determine the benefits and consequences of respecting the client's medical decisions. After the nurse collects the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the client's medical decisions as the next step in the ethical decision-making model. A nurse is caring for a client who was admitted with major depressive disorder (MDD) and states they do not want to attend group therapy. Which of the following responses should the nurse make? A. "Are you experiencing more feelings of depression?" B. "What are your feelings about going to group therapy?" C. "I know you'll make the right decision about going to group therapy." D. "You will feel better after going to group therapy." - B. "What are your feelings about going to group therapy?" The nurse should ask the client open-ended questions because they are therapeutic and allow the client to further discuss their feelings. The nurse should allow the client to discuss their feelings about group therapy in order to involve the client in their own care. A nurse is reinforcing teaching with a caregiver of a client who has histrionic personality disorder. Which of the following manifestations should the nurse tell the caregiver to expect? A. Emotional detachment B. Paranoia C. Attention-seeking behavior D. Fear of abandonment - C. Attention-seeking behavior The nurse should identify that attention-seeking behavior, self-centeredness, and excessive emotionality are expected manifestations in a client who has histrionic personality disorder. A nurse is monitoring communication between a client who has alcohol use disorder and their partner. Which of the following communication pattern of the client's partner should the nurse identify as being effective? A. "I can never talk to you because you are always drunk." B. "I become very angry when you get drunk." C. "Because of your drinking, we can't have guests in our home." D. "Don't be mad at the kids. It was my fault that the dishes did not get done." - B. "I become very angry when you get drunk." The nurse should identify that this statement is an example of a healthy, effective communication pattern. The partner is discussing personal feelings instead of focusing on the client's negative behavior. A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as a predisposing factor for delirium? A. Hepatic failure B. Chronic alcohol use C. Hypertension D. Fluid volume overload - A. Hepatic failure Hepatic failure can be a predisposing factor for the development of delirium. Other potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke. A nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. Exhibit 1: History and Physical Day 1 - 080075-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Cli - Hospital environment is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision or hearing loss, recent surgical procedures, and infection. Older adult is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision and hearing loss, recent surgical procedures, and infection. Postoperative is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision or hearing loss, recent surgical procedures, and infection. Fever is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, the client's age, vision or hearing loss, recent surgical procedures, and infection. A nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Cl - A. Cognitive awareness is correct. C. Blood pressure is correct. E. Sleep/wake cycle is correct. F. I&O is correct. H. Temperature is correct. A nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Cl - Apply restraints is contraindicated. Urinalysis with culture and sensitivity is anticipated. Melatonin is anticipated. MRI of the head is nonessential. IV fluids is anticipated. A nurse is caring for a client who is experiencing delirium. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive - Dropdown 1 Assist with initiating IV fluids is correct. When using Maslow's hierarchy, the nurse should first assist with initiating IV fluids to supplement the client's oral intake. Based on the client's I&O status, the client's output is greater than their input, causing a fluid imbalance. This imbalance could be contributing to the client's manifestations of delirium. Dropdown 2 Administering acetaminophen is correct. When using Maslow's hierarchy, the nurse should administer acetaminophen based on the client's current temperature. The prescription states the medication should be administered for a temperature that is greater than 38.3° C (101° F). This fever could be contributing to the client's manifestations of delirium. A nurse is caring for a client experiencing delirium. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motio - Offer the client warm milk at bedtime is correct. Maintain a low stimulation environment is correct Approach the client from the front and speak slowly is correct. The nurse is reviewing the clients medical record. Exhibit 1: History and Physical Day 1 - 0800 75-year-old client who has osteoarthritis of the knees. Client reports increasing pain to the right knee following their daily 3-mile walk. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Exhibit 2: Nurses' Notes Day 3 - 0800 Client is 3 days postoperative following right knee arthroplasty. Client has operative knee in the continuous passive motion ( - Sleep/wake cycle indicates no change. The client continues to experience confusion and insomnia. Vital signs indicates improvement. All of the client's vital signs are within the expected reference ranges. Daytime orientation indicates improvement. The client is oriented to person, place, and time in the morning, indicating improvement in the client's condition. Glucose level indicates no change. The client's glucose level has remained unchanged and is within the expected reference range. I&O indicates improvement. The client's increased intake from the IV fluids has resolved the fluid imbalance. Pain level indicates improvement. The client's pain rating has dropped from a 5 to a 2 on a scale of 0 to 10, indicating that the client has responded positively to the administration of hydrocodone. Ambulation indicates a decline in condition. The client is not able to ambulate as far as before due to fatigue. A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse expect to administer? A. Naltrexone B. Bupropion C. Varenicline D. Phenobarbital - A. Naltrexone The nurse should expect to administer naltrexone, an opioid antagonist, to a client who is experiencing opioid withdrawal. A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Decreased heart rate C. Slurred speech D. Rhinorrhea - A. Elevated blood pressure Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to 12 hr of cessation of alcohol ingestion.