ATI RN Capstone Mental Health Pre-Assessment

ATI RN Capstone Mental Health Pre-Assessment A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "You are all making fun of me." Which of the following behaviors is this client displaying? a. Grandeur b. Flight of ideas c. Erotomania d. Ideas of reference - d. Ideas of reference Ideas of reference occur when a client believes that conversation of others always concern him and that others are ridiculing him. A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia. Available is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 2 tablet(s) A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? a. "The ritualistic behavior provides sexual satisfaction." b. "The client performs ritualistic behavior to boost self-esteem." c. "The ritualistic behavior temporarily relieves anxiety." d. "The client performs ritualistic behavior to decrease feelings of shame." - c. "The ritualistic behavior temporarily relieves anxiety." Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to obsessions. A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make? a. "You should be aware that excessive sleeping is an early sign of relapse." b. "Relapse is an indication that you are not taking your medications properly." c. "You should keep your provider's and therapist's number with you." d. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear." - c. "You should keep your provider's and therapist's number with you." The client should have a written plan, including important numbers, available at all times in case relapse occurs. A nurse in the emergency department is caring for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (SATA) a. Contact the laboratory to obtain a blood sample. b. Prepare the client for a CT scan. c. Check the client's pupil reactivity. d. Obtain a urine specimen. e. Performa. developmental screening test. - a. Contact the laboratory to obtain a blood sample - A blood sample allows for a blood alcohol level test to be performed. b. Prepare the client for a CT scan - A CT scan or other neurological tests is performed to rule out brain injury or head trauma. c. Check the client's pupil reactivity - Checking for pupil reactivity provides information about a client's neurological status. d. Obtain a urine specimen - A urine specimen is needed to perform a urine toxicology screen. The nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client? a. Disclose some personal information to the client to demonstrate approachability. b. Wait for the client to initiate interaction. c. Approach the client frequently throughout the day for brief interactions. d. Adopt a neutral attitude when providing care. - d. Adopt a neutral attitude when providing care. To promote a therapeutic relationship, the nurse should use a neutral, nonthreatening attitude during care and communication. A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the following information should the nurse include in the teaching? a. "Use a reliable form of contraception while taking this medication." b. "If a dose is missed, double the next dose of medication." c. "This medication may increase your blood pressure." d. "Do not eat aged cheeses while taking this medication." - a. "Use a reliable form of contraception while taking this medication." Alprazolam is a pregnancy category D medication, indicating it causes definitive adverse effects on a fetus. A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds. b. Bradycardia c. Hypertension d. Dental erosion - b. Bradycardia mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. the nurse should anticipate planning care for managing which of the following phobias? a. Xenophobia b. Acrophobia c. Mysophobia d. Agoraphobia - d. Agoraphobia Agoraphobia is an irrational fear about being in places or circumstances where the client would not have help in the event of panic or other forms of anxiety. Fear of being alone outdoor is a common example. A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching? a. "You really shouldn't change the schedule we established here in the facility." b. "Let's work together to devise a time schedule that is convenient for you on a daily basis." c. "We'll have to talk to your provider about switching to an alternative schedule." d. "It doesn't really matter what time you take your medications as long as you don't skip any doses." - b. "Let's work together to devise a time schedule that is convenient for you on a daily basis." This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the client's needs at this time. A nurse is providing discharge teaching to. client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? a. The client runs 4 miles outdoors every afternoon. b. The client drinks 2 liters of liquids daily. c. The client eats 2 to 3 grams of sodium-containing foods daily. d. The client eats foods high in tyramine. - a. The client runs 4 miles outdoors every afternoon. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water that may have been lost through profuse sweating. this also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics. A nurse in a emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?