Mental Health 2020 B NGN EXAM 2023/2024 A+.

Mental Health 2020 B NGN EXAM 2023/2024 A+. 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 disorder volunteers at a head start program. - ANSWER 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 - ANSWER 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 - ANSWER 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 Mental Health 2020 B NGN EXAM 2023/2024 A+. 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 - ANSWER 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?" - ANSWER 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 have the name of the provider who is performing the procedure on the form." - ANSWER 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. - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 balances both the nurse's values and the client's medical decisions. - ANSWER 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.