ATI PN Mental Health Online Practice 2020 A

A nurse is reinforcing teaching with a client whose provider has prescribed electroconvulsive therapy (ECT). Which of the following information should the nurse include? a. The client will receive continuous oxygen during the electrical stimulation intervals. Incorrect (The client will receive oxygen throughout the procedure. However, the oxygen will be removed during the brief electrical stimulation intervals.) b. A benzodiazepine will be administered prior to the procedure. Incorrect (A benzodiazepine should not be administered because it interferes with the seizure process. A short-acting anesthetic, such as propofol, will be administered.) c. ECT is an option for clients after medication has been unsuccessful. d. Confusion is expected for the first 2 days after treatment. (Clients who receive ECT can have confusion and disorientation for several hours after treatment.) - C. ECT is an option for clients after medication has been unsuccessful. (Medication is the first-line of treatment for depression. ECT is prescribed when medication has been unsuccessful.) A nurse is assisting with discharge planning for a client who needs to attend a day treatment center ad has limited community and financial support. Which of the following referrals should the nurse recommend including in the client's discharge plan? A. Social worker B. Recreational therapist(Although recreational therapists can promote therapies, such as art and music, to help enhance and preserve mental health, they do not usually address issues regarding financial support and community resources.) C. Psychologist (Although psychologists can provide individual or family therapy for clients, they do not usually address issues regarding financial support and community resources.) D. Pharmacist (Pharmacists prepare prescribed medications and dispense medications in acute care and community settings. They coordinate with the provider and nurses regarding the client's medication regime. However, they do not address issues regarding financial support and community resources.) - A. Social worker (Social workers can assist clients with building a support structure to help promote and preserve mental health, including contacting day treatment centers and arranging for financial and other community resources.) A nurse is developing countertransference toward a client during the working phase of the nurse-client relationship. To correct the situation, which of the following actions should the nurse take? A. Tell the client how to change their behaviors. (This action places responsibility on the client to correct the situation. When dealing with countertransference, it is the nurse's responsibility to find an appropriate solution.) B. Talk to the client about the developing feelings. (The nurse should avoid disclosing personal feelings because these feelings can interfere with the nurseclient relationship. When dealing with countertransference, it is the nurse's responsibility to find an appropriate solution, not the client's.) C. Ask to be reassigned to a different client. (In order to achieve personal and professional growth, the nurse should work through the issue of countertransference by caring for this client, rather than asking for a new assignment.) D. identify personal response to the client. - D. identify personal response to the client. (Countertransference is an emotional response toward the client by the nurse. This response might be related to the nurse's past unresolved feelings or relationships. These feelings can interfere with the nurse-client therapeutic relationship. In order to correct the situation of countertransference, the nurse must recognize personal reactions to the client in an attempt to work through these feelings.) A nurse is collecting data from a client who has bipolar and a history of mania. Which of the following findings should the nurse identify as an indication that the client is relapsing? A. Weight gain (Weight loss, rather than weight gain, can indicate relapse in a client who has a history of mania.) B. Pressured speech C. Ritualistic behavior (Ritualistic behavior is an indication of obsessivecompulsive disorder, not mania.) D. Anhedonia (Anhedonia is a negative symptom of schizophrenia. Anhedonia is defined as a loss of interest in daily activities and the inability or lack of capacity to experience pleasure in general. This is not an indication of relapse in a client who has a history of mania.) - B. Pressured speech (The nurse should identify that rapid or pressured speech, provocative behavior, and insomnia are indications of potential relapse in a client who has bipolar disorder and a history of mania.) History and Physical Subjective: Client states, "My stomach hurts."; "I feel sadder and more alone every day." Client's adult child stated to the nurse upon dropping the client off today, "I've been meaning to tell you, I started giving my dad St. John's wort several weeks ago to improve his mood." Objective: Episodes of speech incoherency, rapid mood swings, 3 episodes of vomiting in the past 40 min Moderate Alzheimer's disease. Provider Prescriptions Fluoxetine 20 mg PO daily Trazodone 50 mg PO daily at bedtime Omeprazole 20 mg PO daily Diagnostic Results Blood pressure 172/94 mm Hg Temperature 38.2° C (100.8° F) Pulse rate 110/min Respiratory rate 24/min A nurse is caring for a client in a day treatment program. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data) A. Request transport for the client to an emergency department. B. Place a hypothermia blanket on the client. (There is no indication that a hypothermia blanket is necessary for this client.) C. Discontinue the client's fluoxetine therapy immediately. (Fluoxetine should not be discontinued abruptly because this can cause the client to exhibit manifestations of withdrawal.) D. Implement droplet precautions for the client. (There is no indication for the implementation of droplet precautions for this client. Droplet precautions are used for clients who have diseases that are transmitted by large droplets that are expelled into the air.) - A. Request transport for the client to an emergency department. (The nurse should request transport for the client to the nearest emergency department because the client has manifestations of serotonin syndrome. Serotonin syndrome is a life-threatening syndrome and is caused by an over activation of the central serotonin receptors. This is related to interactions with taking an SSRI and trazodone along with St. John's wort. Manifestations of serotonin syndrome include hypertension, tachycardia, vomiting, abdominal pain, and mental status changes.) A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explains the therapeutic and adverse effects of the medication to the client prior to administration. which of the following ethical concepts is the nurse demonstrating? A. Autonomy (Autonomy involves respecting the client's right to make their own decision. The nurse is currently providing information. The client has not made a decision yet about taking the medication.) B. Justice (Justice means distributing care or resources equally among clients or groups of clients. The nurse is currently caring for an individual client who requires information about a prescribed medication.) C. Veracity D. Confidentiality (Confidentiality means respecting the client's privacy regarding personal issues. The nurse should uphold this ethical principle when making decisions about sharing client information with others.) - C. Veracity (Veracity is the duty to tell the truth. The nurse should uphold this ethical principle when administering a new medication to a client by explaining the therapeutic effects as well as the adverse effects. This action promotes a trusting relationship between the nurse and the client, which enhances the nurse's primary commitment to the client of providing optimum, quality care.) A nurse is preparing to administer haloperidol 3 mg IM to a client. Available is haloperidol solution 5 mg/mL. How many mL should the nurse plan to administer? - 5 mg3 mg = 1 mL X mL X mL = 0.6 mL Step 7: Round if necessary A nurse is caring for a client who has anxiety disorder and is refusing to take a medication which of the following responses should the nurse make? A. "This medication is safe for you to take." (This response devalues the client's concerns, gives false reassurance, and discourages further communication about the motivation behind the client's refusal.) B. "You have the right to refuse this medication." C. "You are presenting a risk to the other clients." (This response places blame on the client and rejects their choice without exploring the motivation behind it.) D. "This medication is part of your treatment plan." (This response fails to encourage the client to explore their feelings of anxiety and to participate in devising or accepting strategies to manage it) - B. "You have the right to refuse this medication." ( Clients have the right to refuse treatment, including medications, unless the client undergoes a court hearing and the judge decides that the client meets the criteria for involuntary medication administration.) A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect. A. Preoccupied with perfectionism (The nurse should expect a client who has obsessive-compulsive personality disorder to have manifestations of being preoccupied with details.) B. Uses attention-seeking behaviors (The nurse should expect a client who has histrionic personality disorder to have manifestations of attention-seeking behaviors.) C. Exploitative of others (The nurse should expect a client who has antisocial behavior to have manifestations of exploiting others.) D. Projects blame onto others - D. Projects blame onto others (The nurse should expect clients who have paranoid personality disorder to project blame onto others rather than taking responsibility for their own actions.) A nurse is caring for a client who is 2 days post-op following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse. "My youngest child died 6 months ago while serving in the military." Which of the following responses should the nurse make? (Select all that apply) A. "This must be a very difficult time for you." B. "Your child's death must be a terrible loss." C. "It's just awful what is going on in the world." is incorrect. (This statement demonstrates a nontherapeutic response because it changes the subject and diverts attention away from the client's grief. This belittles and invalidates the client's feelings.) D. "You need to focus on getting better." is incorrect. (This statement demonstrates a nontherapeutic response because it negates the client's feelings and makes the assumption that the nurse knows best. This prevents problem-solving and can cause the client to feel misunderstood, insignificant, and unsupported.) E. "Tell me something you remember about your child." - A. "This must be a very difficult time for you." (This statement demonstrates the use of reflecting. Reflecting expresses the nurse's observations of the client's verbal and nonverbal behaviors when discussing sensitive issues. This therapeutic communication technique encourages clients to accept and embrace their own feelings.) B. "Your child's death must be a terrible loss." (This statement demonstrates the use of reflecting. Reflecting expresses the nurse's observations of the client's verbal and nonverbal behaviors when discussing sensitive issues. This therapeutic communication technique encourages clients to accept and embrace their own feelings.) E. "Tell me something you remember about your child." (This statement demonstrates the use of exploring. Exploring acknowledges the client's feelings and facilitates communication between the client and the nurse.) A nurse is assisting with screening a group of clients for major depressive disorder (MDD). The nurse should identify that which of the following clients is at an increased risk for the development of MDD? A. A client who is newly employed. (There is a relationship between socioeconomic class and depression. However, it is not proven that employment status has an effect on the development of MDD.) B. A client who abstains from alcohol (Clients who have alcohol or substance use disorders are at an increased risk for developing MDD.) C. A client who just gave birth D. A client who has been married for 15 years (Clients who are married are at a decreased risk for developing MDD. Marriage or close relationships have been shown to have a calming effect on the well-being of an individual's psychological status when compared to those who are single or who lack a close relationship with another person) - C. A client who just gave birth (Clients who just gave birth or are in the early postpartum period are at an increased risk for developing MDD or postpartum depression.) A nurse is assisting with the admission of a client who has schizophrenia. A. Conduct an abnormal involuntary movement scale test. B. Discuss behavioral expectations with the client. (Discussing behavioral expectations with the client is important to encourage expected behavior and to discourage undesirable behavior. However, there is another action that the nurse should take first.) C. Orient the client to unit routines. (Orienting the client to unit routines is important to create a sense of security and promote a therapeutic environment. However, there is another action that the nurse should take first.) D. Encourage the client to attend group art sessions. (Participation in art therapy, such as drawing or listening to music, can assist a client with recognition and expression of specific feelings. However, there is another action that the nurse should take first) - A. Conduct an abnormal involuntary movement scale test. (The first action the nurse should take when using the nursing process is to collect data. The abnormal involuntary movement scale (AIMS) test is a data collection tool used to guide medication therapy for clients who are prescribed antipsychotic medications. Therefore, the first action the nurse should take is to conduct the AIMS test.) A nurse is contributing to the plan of care for a client who has obsessivecompulsive disorder and continually washes her hands. Which of the following interventions should the nurse include? A. Inform the client that excessive handwashing is a negative behavior. (This can increase anxiety, rather than decrease the need for handwashing, and is not an effective intervention for the nurse to include in the plan of care.) B. Do not allow the client to use a private restroom. (This can increase anxiety) C. Schedule times for the client to wash their hands during the day. D. Explain that unit privileges will be taken away if excessive handwashing continues. (This can increase anxiety) - C. Schedule times for the client to wash their hands during the day. (Providing a schedule is a type of response prevention and can decrease anxiety by allowing the client to know in advance when handwashing can be performed.) A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider. A. Inability to make decisions (This affects the client's concentration, which decreases the client's ability to complete tasks. However, another finding is the priority to report.) B. Anhedonia (Anhedonia is the lack of pleasure or interest in activities or the lack of the capacity to experience pleasure. However, another finding is the priority to report.) C. Feelings of hopelessness D. Fatigue (indicates that the client is at risk for inability to complete ADLs. However, another finding is the priority to report) - C. Feelings of hopelessness (When using the urgent vs. nonurgent approach to client care, the nurse should identify that feelings of hopelessness indicate that this client is at risk for suicide. Therefore, this is the priority finding for the nurse to report to the provider.) A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse include? A. Occupational therapist (works with clients who have impaired functioning and assists in the performance of ADLs. However, there is no indication that a client who has acute anorexia nervosa requires occupational therapy. Therefore, a client who has acute anorexia nervosa does not require an occupational therapist.) B. Physician assistant(performs tasks under the supervision of the physician and provides primary care in the physician's office.) C. Nurse researcher (can conduct research about the nursing care of clients who have mental health disorders) D. Dietitian - D. Dietitian (The nurse should plan to include the facility dietitian in an interprofessional care conference to assist with the creation of a treatment plan for a newly admitted client who has acute anorexia nervosa. A dietitian can evaluate the client to determine daily caloric intake requirements and the client's food likes and dislikes, which are necessary to achieve the client's target weight. A dietitian can also provide teaching to the client about nutrition.) A nurse is monitoring the nutritional status of a client who has bulimia nervosa. The nurse should monitor the client for which of the following complications? A. Hyperchloremia (The nurse should monitor clients who have bulimia nervosa for hypochloremia, not hyperchloremia.) B. Hyponatremia C. Decreased bone density (Decreased bone density is a potential complication of anorexia nervosa, not bulimia nervosa.) D. Increased WBC count (An increased WBC count is an indication of infection. However, this is not an expected complication of bulimia nervosa.) - B. Hyponatremia ( The nurse should monitor clients who have bulimia nervosa for hyponatremia, which results from purging, vomiting, and laxative and/or diuretic use.) A nurse is caring for a client takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statements indicates the medication is effective? A. "Naltrexone calms my nerves." (Naltrexone is a narcotic antagonist, not an antianxiety medication.) B. "I get flushed when I drink alcohol while taking naltrexone." (A client can experience flushing with the concurrent use of alcohol and disulfiram. However, flushing is not an adverse effect of naltrexone.) C. "Naltrexone decreases my fine hand tremors." D. "I drink less alcohol in a day while taking naltrexone." - D. "I drink less alcohol in a day while taking naltrexone." (Clients who take naltrexone have a decreased craving for alcohol and experience decreased pleasurable effects from alcohol consumption. Although the goal for most clients who have alcohol use disorder is to maintain abstinence, clients who ingest alcohol while taking this medication often drink less per day.) A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client's confidentiality? A. The nurse documents subjective data about the client's condition in the client's medical record. B. The nurse places the client's diagnosis on the whiteboard in the client's room. C. The nurse faxes the client's allergies to the pharmacy. D. The nurse reports threats that the client made to harm their partner to the provider. - B. The nurse places the client's diagnosis on the whiteboard in the client's room. (Writing information about the client's diagnosis or medical condition on the whiteboard in the client's room is a violation of HIPAA. However, message boards in the client's room can be used to post nursing care information.) A nurse is reinforcing teaching with a client who has schizophrenia a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching? A. "The voices you have been hearing should decrease." B. "You will likely have more energy while on this medication." (Chlorpromazine causes sedation) C. "You should now be able to spend more time in the sun." D. "Call your provider immediately if you develop a dry mouth." - A. "The voices you have been hearing should decrease." (The nurse should instruct the client that hallucinations and agitated behavior, which are positive symptoms of schizophrenia, are targeted by conventional antipsychotic agents, such as chlorpromazine.) A nurse is caring for an older adult client who is about to undergo screening with the mental status examination (MSE). The client asks about the purpose of this test. Which of the following responses should the nurse make? A. "We're just going to ask you some very simple questions." (This response by the nurse is changing the subject, which is nontherapeutic communication and does not address the client's concerns.) B. "This test will collect information about your family history." (The MSE does not require information about family history. It is an assessment of the client's current memory, speech, and cognition.) C. "You are going to be okay. There is nothing to worry about." (This response by the nurse is providing false reassurance) D. "This test will give us information about how you remember things." - D. "This test will give us information about how you remember things." (The MSE tests the cognitive function of the client. It is an assessment of the client's current memory, speech, and cognition.) A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? A. Call for assistance to place the client in restraints. (The nurse should identify that the client might need to be placed in restraints if all other means of deescalation are ineffective. However, there is another action that is the priority.) B. Administer a sedative to the client. (The nurse should identify that the client might need medication to decrease aggression and anxiety if other means of deescalation are ineffective. However, there is another action that is the priority.) C. Determine the client's intentions. D. Place the client into the assigned seclusion room. (The nurse should identify that the client might need to be placed into the assigned seclusion room and monitored one-on-one to prevent self-endangerment if other actions are ineffective. However, there is another action that is the priority.) - C. Determine the client's intentions. (The first action the nurse should take when using the nursing process is to collect data from the client. By determining the client's intentions, the nurse can de-escalate the situation by talking to the client in a calm manner. This intervention will assist the nurse in establishing a trusting relationship with the client.) A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few moments later, the client cheerfully states, "Now, here is my social worker!" The nurse should identify the client is using which of the following defense mechanisms? A. Reaction formation B. Dissociation (Dissociation is the defense mechanism in which unpleasant or anxiety-producing memories or experiences are separated from the client's awareness to decrease anxiety.) C. Denial (Denial is the defense mechanism in which the client ignores unpleasant or anxiety-producing events to decrease anxiety.) D. Projection (Projection is the defense mechanism in which the client has feelings or behaviors that are personally unacceptable. As a result, the client attributes these feelings to others to decrease anxiety.) - A. Reaction formation (The nurse should identify that this client is using reaction formation. This is the defense mechanism in which the client is unable to process unacceptable feelings or behaviors and expresses the opposite to decrease anxiety.) A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take? A. Insist that the client report the incident to the authorities before beginning treatment. (Client safety, including treatment for the client's injuries, should be the nurse's priority. The nurse should support the client's decision to seek treatment, and the nurse should ask the client if they need assistance with making a report. However, it is the client's choice whether or not to report the incident to authorities. Members of the health care team might be required to report partner violence themselves if the client has been assaulted by a weapon or if rape has occurred, depending on individual state laws.) B. Encourage the client to develop a safety plan. C. Recommend that the partner remain in the room during the interview with the client. (The nurse should interview the client privately without the partner present.) D. Advise the client to obtain an order of protection from the court. (Giving advice is not a therapeutic technique. The nurse should offer support for the client's own decisions and refrain from offering advice) - B. Encourage the client to develop a safety plan. (The nurse should encourage the client to develop a safety plan to aid in escaping further violence if necessary.) A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse take first? A. Remove harmful objects from the client's room. B. Decrease the client's environmental stimuli. (The nurse should decrease the environmental stimuli to assist with decreasing manifestations of mania. However, there is another action that the nurse should take first.) C. Administer an antipsychotic medication to the client. (The nurse might need to administer an antipsychotic medication to decrease manifestations of mania. However, there is another action that the nurse should take first.) D. Provide physical activities for the client. (The nurse should provide an opportunity for the client to participate in physical activities to relieve tension. However, there is another action that the nurse should take first.) - A. Remove harmful objects from the client's room. (The greatest risk to this client is self-injury or injury to others. Therefore, the first action the nurse should take is to remove harmful objects from the client's room to protect the client.)