Mental Health (ATI)- Chapter 16, 17, 18, 20, 21, 23

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

a: "I can promote my clients sense of control by stablishing a schedule"

b: "I should encourage clients who have schizoid personality disorder to increase socialization"

c: "I should practice limit-setting to help prevent client manipulation"

d: "I should implement assertiveness training with clients who have antisocial personality disorder"

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who as this type of personality disorder?

a: "Im scared that youre going to leave me"

B: "Ill go to group therapy if youll let me smoke"

c: "I need to feel that everyone admires me"

d: "I sometimes feel better if i cut myself"

a: "Im scared that youre going to leave me"

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms?

A. Regression

B. Splitting

C. Undoing

D. Identification

B. Splitting

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this client, which of the following are expected findings? (Select all that apply.)

A. Demonstrates extreme anxiety when placed in a social situation

B. Has difficulty making even simple decisions

C. Attempts to convince other clients to give him their belongings

D. Becomes agitated if his personal area is not neat and orderly

E. Blames others for his past and current problems

C. Attempts to convince other clients to give him their belongings

E. Blames others for his past and current problems

A charge nurse is preparing a staff education session on personality disorders. Which of the followings hould be included as personality characteristics associated with all of the personality disorders? (Select allthat apply.)

A. Difficulty in getting along with other members of a group

B. Belief in the ability to become invisible during times of stress

C. Display of defense mechanisms when routines are changed

D. Claiming to be more important than other persons

E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

A. Difficulty in getting along with other members of a group

C. Display of defense mechanisms when routines are changed

E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?

a. you should avoid taking OTC acetaminophen while on donepezil

b. you can expect the progression of cognitive decline to slow with donepezil

c. you will be screened for underlying kidney disease prior to starting donepezil

d. you should stop taking donepezil if you experience nausea or diarrhea

b. you can expect the progression of cognitive decline to slow with donepezil

A nurse in a long term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make?

a. you have forgotten that this is your home

b. you cannot go outside without a staff member

c. why would you want to leave? Aren't you happy with your care?

d. I am your nurse. Let's walk together to your room

d. I am your nurse. Let's walk together to your room

A home health nurse is making a visit to a client who has alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? (select all that apply)

a. install childproof door locks

b. place rugs over electrical cords

c. mark cleaning supplies with colored tape

d. place the client's mattress on the floor

e. install light fixtures above stairs

a. install childproof door locks

d. place the client's mattress on the floor

e. install light fixtures above stairs

A nurse is making a home visit to a client who is in the late stage of alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take?

a. verify that a current power of attorney document is on file

b. instruct the clients partner to offer finger foods to increase oral intake

c. provide information on resources for respite care

d. schedule the client for placement of an enteral feeding tube

c. provide information on resources for respite care

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (select all the apply)

a. history of gradual memory loss

b. family report of personality changes

c. hallucinations

d. unaltered level of consciousness

e. restlessness

b. family report of personality changes

c. hallucinations

e. restlessness

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? select all that apply

a. hypothermia

b. hallucinations

c. muscular flaccidity

d. diaphoresis

e. agitation

b. hallucinations

d. diaphoresis

e. agitation

A nurse is caring for a client who is prescribed lithium therapy. The client tells of the plan to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?

A. "That is a good choice. Ibuprofen does not interact with lithium"

B. "Regular aspirin would be a better choice than ibuprofen"

C. "Lithium decreases the effectiveness of ibuprofen"

D. "The ibuprofen will make your lithium level fall too low"

B. "Regular aspirin would be a better choice than ibuprofen"

A nurse is discussing early indications of toxicity with a client who has a new script for lithium carbonate for bipolar. The nurse should include which of the following manifestations in the teaching? (SATA)

A. Constipation

B. Polyuria

C. Rash

D. Muscle Weakness

E. Tinnitus

B. Polyuria

D. Muscle Weakness

A nurse is discussing routine follow-up needs with a pt who has a new script for valproate. The nurse should inform the pt of the need for routine monitoring of which of the following?

A. AST/ALT and LDH

B. Creatinine and BUN

C. WBC and granulocyte counts

D. Blood sodium and potassium

A. AST/ALT and LDH

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the pt's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take?

A. Administer the next dose of lithium carbonate as scheduled

B. Prepare for administration of Aminophylline

C. Notify the provider for a possible increase in the dosage of lithium carbonate

D. Request a stat repeat of the client's lithium blood level.

A. Administer the next dose of lithium carbonate as scheduled

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is priority to report to the provider?

A. "Current medical conditions include diabetes that is controlled by diet"

B. "Recent medications include a course of prednisone for acute bronchitis.

"C. "Current vaccinations include a flu vaccine last month."

D. "Current meds include furosemide for congestive heart failure."

D. "Current meds include furosemide for congestive heart failure."