NGN Mental Health Practice B with Verified Answers Graded A+
Identify signs of escalation of violence
It is important for the client to be able to identify signs of
Client in abusive relationship and is assisting in the devel-
escalation of violence, which are the greatest risk to the
opment of a safety plan. First component of a safety plan?
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.
Reduce environmental stimuli
Child with conduct disorder and is behaving in a destruc-
The greatest risk to the child and others is harm. Therefore,
tive manner, throwing objects, and kicking others. Priority
the nurse's priority intervention is to reduce environmental
therapeutic nursing intervention?
stimuli in an attempt to de-escalate the behavior and
prevent injury.
Identify the client's trigger foods
Nurse is updating the plan of care for a client who has
bulimia nervosa and is 5% above their ideal body weight. The nurse should identify the trigger foods that initiate
Which intervention should the nurse include in the plan? the client's binge and assist the client to understand their
thoughts and behavior that relate to the food.
"I am going to order a wheelchair for when I am unable
to walk"
Nurse is assisting a client who has terminal illness adjust
to progressive loss of independence. Client statement The client is recognizing the reality of continued loss of
indicates acceptance of illness? independence and is anticipating the need for assistive
devices, which indicates the behavioral response of accep-
tance.
Acute dystonia
Medication administration record for a client who is expe-
riencing adverse ettects of chlorpromazine. Nurse should
The nurse should administer benztropine, an anticholiner-
administer benztropine to relieve which of the following
gic agent, to relieve acute dystonia, which is an extrapyra-
adverse ettects?
midal adverse ettect of chlorpromazine.
A nurse is carnig for an older adult client who is experienc-
ing delirium. Which intervention should the nurse include
in the client's plan of care?
,Permit the client to perform daily rituals to decrease anx-
iety.
The nurse should provide a client who has delirium with
a plan of care that decreases agitation and anxiety by
permitting the client to perform daily rituals.
A client who is taking clozapine and reports a sore throat
and chills
When using the urgent vs. nonurgent approach to client
Nurse is receiving change of shift report for four clients.
care, the nurse should determine to first see the client who
Which client should the nurse see first?
is taking clozapine and reports a sore throat and chills.
Clozapine can cause agranulocytosis, a serious adverse
ettect that causes neutropenia. The nurse should withhold
the medication and notify the provider of these findings.
Nonmaleficence
Nurse is planning care for client who has made repeated
physical threats toward others on the unit. Although the It is the responsibility of the nurse to do no harm to clients.
client does not want to leave the uhnit, the nurse requests The nurse is applying the ethical principle of nonmalefi-
that provider to transfer the client to a unit that is equippt- cence by requesting to transfer this client to a unit better
ed to manage violent behavior. Which ethical principle? able to manage their behavior and thereby prevent injury
to others on the unit.
Nurse is performing cognitive assessment to distinguish Easily distracted
delirium from dementia in a client whose family reports
episodes fo confusion. Which assessment finding sup- Extreme distractibility is a hallmark manifestation of delir-
ports delirium? ium.
Nurse is creating plan of care for a client who has been Renew the prescription for the client every 4 hr.
placed in seclusion after threatening to harm others on
the unit. Which intervention should the nurse include in The nurse should assess the client's behavior frequently
the plan? during seclusion and should renew the prescription for
, seclusion for an adult client every 4 hr, for a maximum of
24 hr.
Move the client who has bipolar disorder to a private
Client has recent diagnosis of biopolar disorder is placed room.
in room with client with severe depression. . Depression
says "my roommate never sleeps and keeps me up too" Clients who have bipolar disorder can disrupt the thera-
Which action should the nurse take? peutic milieu for other clients. Therefore, the nurse should
move this client to a private room.
Inability to sleep
Nurse is teaching partner of client who has bipolar disor-
der how to identify manifestations of acute mania. Which During acute mania, the client is extremely active and does
finding should the client's partner report to the provider? not sleep, which can lead to exhaustion. Therefore, the
nurse should instruct the partner to report this finding.
"I will talk about my feelings with a close friend."
Coping strategies to a client who is experiencing depres-
Discussing feelings, such as fear and depression, with a
sion related to partner violence. Statement is understand-
support person is an ettective coping strategy and can
ing of teaching?
provide the client with emotional support and other re-
sources.
"It is common for people who survived a traumatic event to
experience feelings of anxiety" is correct. Clients who have
experienced a traumatic event can demonstrate mani-
festations of severe anxiety and panic attacks, including
impulsivity and regression.
Nurse at an inpatient mental health facility is caring for a
client who recently experienced a traumatic event. "A support group might be helpful to you during this
time" is correct. The nurse should encourage the client to
participate in a support group, which can provide emo-
tional support for a client who has experienced a traumatic
event.
Identify signs of escalation of violence
It is important for the client to be able to identify signs of
Client in abusive relationship and is assisting in the devel-
escalation of violence, which are the greatest risk to the
opment of a safety plan. First component of a safety plan?
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.
Reduce environmental stimuli
Child with conduct disorder and is behaving in a destruc-
The greatest risk to the child and others is harm. Therefore,
tive manner, throwing objects, and kicking others. Priority
the nurse's priority intervention is to reduce environmental
therapeutic nursing intervention?
stimuli in an attempt to de-escalate the behavior and
prevent injury.
Identify the client's trigger foods
Nurse is updating the plan of care for a client who has
bulimia nervosa and is 5% above their ideal body weight. The nurse should identify the trigger foods that initiate
Which intervention should the nurse include in the plan? the client's binge and assist the client to understand their
thoughts and behavior that relate to the food.
"I am going to order a wheelchair for when I am unable
to walk"
Nurse is assisting a client who has terminal illness adjust
to progressive loss of independence. Client statement The client is recognizing the reality of continued loss of
indicates acceptance of illness? independence and is anticipating the need for assistive
devices, which indicates the behavioral response of accep-
tance.
Acute dystonia
Medication administration record for a client who is expe-
riencing adverse ettects of chlorpromazine. Nurse should
The nurse should administer benztropine, an anticholiner-
administer benztropine to relieve which of the following
gic agent, to relieve acute dystonia, which is an extrapyra-
adverse ettects?
midal adverse ettect of chlorpromazine.
A nurse is carnig for an older adult client who is experienc-
ing delirium. Which intervention should the nurse include
in the client's plan of care?
,Permit the client to perform daily rituals to decrease anx-
iety.
The nurse should provide a client who has delirium with
a plan of care that decreases agitation and anxiety by
permitting the client to perform daily rituals.
A client who is taking clozapine and reports a sore throat
and chills
When using the urgent vs. nonurgent approach to client
Nurse is receiving change of shift report for four clients.
care, the nurse should determine to first see the client who
Which client should the nurse see first?
is taking clozapine and reports a sore throat and chills.
Clozapine can cause agranulocytosis, a serious adverse
ettect that causes neutropenia. The nurse should withhold
the medication and notify the provider of these findings.
Nonmaleficence
Nurse is planning care for client who has made repeated
physical threats toward others on the unit. Although the It is the responsibility of the nurse to do no harm to clients.
client does not want to leave the uhnit, the nurse requests The nurse is applying the ethical principle of nonmalefi-
that provider to transfer the client to a unit that is equippt- cence by requesting to transfer this client to a unit better
ed to manage violent behavior. Which ethical principle? able to manage their behavior and thereby prevent injury
to others on the unit.
Nurse is performing cognitive assessment to distinguish Easily distracted
delirium from dementia in a client whose family reports
episodes fo confusion. Which assessment finding sup- Extreme distractibility is a hallmark manifestation of delir-
ports delirium? ium.
Nurse is creating plan of care for a client who has been Renew the prescription for the client every 4 hr.
placed in seclusion after threatening to harm others on
the unit. Which intervention should the nurse include in The nurse should assess the client's behavior frequently
the plan? during seclusion and should renew the prescription for
, seclusion for an adult client every 4 hr, for a maximum of
24 hr.
Move the client who has bipolar disorder to a private
Client has recent diagnosis of biopolar disorder is placed room.
in room with client with severe depression. . Depression
says "my roommate never sleeps and keeps me up too" Clients who have bipolar disorder can disrupt the thera-
Which action should the nurse take? peutic milieu for other clients. Therefore, the nurse should
move this client to a private room.
Inability to sleep
Nurse is teaching partner of client who has bipolar disor-
der how to identify manifestations of acute mania. Which During acute mania, the client is extremely active and does
finding should the client's partner report to the provider? not sleep, which can lead to exhaustion. Therefore, the
nurse should instruct the partner to report this finding.
"I will talk about my feelings with a close friend."
Coping strategies to a client who is experiencing depres-
Discussing feelings, such as fear and depression, with a
sion related to partner violence. Statement is understand-
support person is an ettective coping strategy and can
ing of teaching?
provide the client with emotional support and other re-
sources.
"It is common for people who survived a traumatic event to
experience feelings of anxiety" is correct. Clients who have
experienced a traumatic event can demonstrate mani-
festations of severe anxiety and panic attacks, including
impulsivity and regression.
Nurse at an inpatient mental health facility is caring for a
client who recently experienced a traumatic event. "A support group might be helpful to you during this
time" is correct. The nurse should encourage the client to
participate in a support group, which can provide emo-
tional support for a client who has experienced a traumatic
event.
