ATI RN Mental Health Online Practice 2019 B with NGN

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A. Lansoprazole B. Naproxen C. Magnesium hydroxide D. Phenylephrine - D. Phenyleprine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who was hit for injuries. - C. Call for a team of staff members to help with the situation The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others. A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A. An adolescent family member who questions parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household - C. Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members A nurse is assessing a client who had major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in affect within 30 to 60 min after taking the medication B. Greater risk of attempting suicide as affect and energy improve C. Onset of frequent, loose stools D. Development of physiologic dependence on the medication - B. Greater risk of attempting suicide as affect and energy improve The nurse shoud identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use the same plan of care and interventions for each client who has depression." B. "Each nurse will develop a separate plan of care for each client who has depression." C. "I will update the plan of care as a client's manifestations of depression change." D. "An assisst - C. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change. A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A. A school-age child who has bruises on the knee B. An older adult client who is bedbound and has a stage IV pressure ulcer C. An adolescent who has a vaginal candida infection D. A young adult who is pregnant and has a sprained ankle