Mental Health ATI Practice B

NGN IINFO:

A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event.

Nurses' Notes

0730 Admission:

Client was a witness during a recent violent crime at their place of employment. Several of the client's coworkers were killed. The client has been experiencing feelings of guilt and anger.

1400:

The client continues to express feelings of guilt and anger and states, "I cannot ever go back to work. It is too dangerous." The client also states, "I don't know why I was allowed to survive. It's too painful to talk to my friends and family about what happened."

Vital Signs

0730:

Temperature 36.6° C (97.8° F)

Heart rate 74/min

Respiratory rate 16/min

Blood pressure 118/74 mm Hg

1400:

Temperature 36.9° C (98.4° F)

Heart rate 86/min

Respiratory rate 18/min

Blood pressure 114/78 mm Hg

The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

-"A support group might be helpful to you during this time."

-"It is common for people who survived a traumatic event to experience feelings of anxiety."

-"You should seek help if you have thoughts of self-harm."

-"It is uncommon for people who survived a traumatic event to experience spiritual distress."

-"You will have minimal problems performing your daily self-care tasks."

ANS:

-"A support group might be helpful to you during this time."

-"It is common for people who survived a traumatic event to experience feelings of anxiety."

-"You should seek help if you have thoughts of self-harm."

Rationale:

-The nurse should encourage the client to participate in a support group, which can provide emotional support for a client who has experienced a traumatic event.

-Clients who have experienced a traumatic event can demonstrate manifestations of severe anxiety and panic attacks, including impulsivity and regression.

- The nurse should inform the client that they should seek help immediately if they experience thoughts of self-harm or suicidal ideation.

"It is uncommon for people who survived a traumatic event to experience spiritual distress" is incorrect. Clients who have experienced a traumatic event can experience spiritual distress.

"You will have minimal problems performing your daily self-care tasks" is incorrect. Clients who have experienced a crisis can have difficulty meeting their basic needs and performing self-care tasks. The nurse might need to assist the client to perform ADLs.

NGN INFO:

A nurse is caring for a client who has alcohol use disorder.

Vital Signs

0800:

Blood pressure 116/68 mm Hg

Heart rate 80/min

Respiratory rate 14/min

Temperature 36.8° C (98.2° F)

1200:

Blood pressure 120/84 mm Hg

Heart rate 96/min

Respiratory rate 20/min

Temperature 37° C (98.6° F)

Nurses' Notes

0800:

Client alert and oriented to time, place, person, and situation. Visiting with other clients in the dayroom. Attended group session this morning and stated, "I think I'm beginning to see what I need to do to get better." Eager to have family visit with partner later this morning.

1230:

Client attended lunch with other clients but refused to eat or drink today. Staring intently at other clients and nursing staff. Posture is rigid and jaw is clenched. Pacing and restless.

Complete the following sentence by using the list of options.

The client is at greatest risk for_____1___as evidenced by

the client's ___2___

Drop down 1:

ineffective coping

dehydration

violent behavior

Drop down 2:

Agitation

loss of appetite

inability to perform simple tasks

ANS:

1: Violent Behavior

2: Agitation

Rationale;

Drop down 1

Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcohol, which is causing them increasing agitation. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury.

Ineffective coping is incorrect. The nurse should continue to monitor the client for ineffective coping and encourage the client to use coping techniques. However, this is not the greatest risk for this client.

Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for this client.

Drop down 2

Agitation is correct. The client is at greatest risk of engaging in violent behavior as evidenced by the client's agitation, which can be indicated by pacing, restlessness, staring, silence, rigid posture, and clenched jaw. The nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury.

Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink. However, this is not the greatest risk for the client. Loss of appetite is an expected finding for a client who is experiencing alcohol withdrawal.

Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to perform simple tasks and encourage use of coping strategies. However, this is not the greatest risk for the client.

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?

Advise the client to take frequent sips of water.

Recommend that the client exercise regularly.

Consult a dietitian for a calorie-controlled diet plan.

Instruct the client to avoid driving during initial therapy.

ANS: Instruct the client to avoid driving during initial therapy.

Rationale;

The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.

The nurse should advise the client to take frequent sips of water due to the adverse effect of dry mouth. However, this is not the nurse's priority intervention.

The nurse should advise the client to exercise regularly due to the adverse effects of weight gain and constipation. However, this is not the nurse's priority intervention.

The nurse should consult a dietitian for a calorie-controlled diet plan due to the adverse effect of weight gain. However, this is not the nurse's priority intervention.

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

The client will take prescribed medications as scheduled.

The client will express feelings of frustration.

The client will refrain from self-mutilation.

The client will participate in group therapy.

ANS: The client will refrain from self-mutilation.

Rationale;

The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the client to refrain from self-mutilation.

Taking prescribed medications as scheduled to maintain therapeutic blood levels is an important goal. However, this is not the priority goal.

Expressing feelings of frustration to acknowledge these feelings is an important goal. However, this is not the priority goal.

Participating in group therapy as part of the treatment plan is an important goal. However, this is not the priority goal.

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

"It will be better for you to keep busy to avoid thinking about your child's death."

"You will complete the grieving process about a year after your child's death."

"The grief process will start once your child actually dies."

"It is not uncommon to feel angry toward yourself or others."

ANS: "It is not uncommon to feel angry toward yourself or others."

Rationale;

Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.

Encouraging the client to avoid thinking about the child's death will not allow the client to begin anticipatory grieving.

The grief process has no timeline. It varies for each individual.

The client can begin anticipatory grieving during the child's illness.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?

Controls anger outbursts to avoid being placed in seclusion

No longer exhibits a fear of social or public situations

Refrains from manipulating others to earn dining room privileges

Imitates the therapist's use of a relaxation technique

ANS: Refrains from manipulating others to earn dining room privileges

Rationale;

The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response.

Changing behavior to avoid punishment is not an optimal goal of operant conditioning therapy.

There is no evidence that this client has a social phobia. Phobias are usually treated with desensitization therapy.

Imitating behavior is modeling and does not demonstrate the desired outcome of operant conditioning.

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

______mL

ANS: 14 mL

Rationale:

conversions:

1kg=2.2 lb

0.55 mg/kg

10mg/5mL

110lb/2.2lb = 50kg

50kg x 0.55 mg = 27.5 mg

27.5 mg/10mg x 5mL = 13.75 mL

13.75 mL rounded nearest whole number = 14 mL

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?

Amenorrhea

Lanugo

Cold extremities

Tooth erosion

ANS: Tooth Erosion

Rationale:

A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

A client who has anorexia nervosa is more likely to have amenorrhea(absence of menstrual periods) resulting from low body weight.

A client who has anorexia nervosa is more likely to have lanugo(soft, fine, unpigmented hair) resulting from extreme malnutrition.

A client who has anorexia nervosa is more likely to have cold extremities from extreme malnutrition.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month.

The client reports an inability to breathe easily.

The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL (74 to 106 mg/dL)

The client reports having recently started smoking cigarettes.

ANS: The client reports an inability to breathe easily.

Rationale;

Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations and should be reported to the provider.

Weight gain is an adverse effect of clozapine that can also lead to hyperlipidemia and hyperglycemia. The nurse should notify the provider so additional laboratory tests and nutritional counseling can be prescribed. However, this is not the priority finding for the nurse to report to the provider.

Hyperglycemia is an adverse effect associated with clozapine. The nurse should notify the provider so additional laboratory tests and nutrition counseling can be prescribed. However, it is not the priority finding for the nurse to report to the provider.

Nicotine decreases the concentration of clozapine in the system. The nurse should identify that the client might require dosage adjustment and report this finding to the provider. However, it is not the priority finding to report to the provider.

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

Male gender

Hyperthyroidism

Substance use disorder

Being married

ANS: Substance use disorder

Rationale;

The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

The nurse should identify that female clients are at an increased risk for the development of depressive disorders.

The nurse should identify that clients who have hypothyroidism are at an increased risk for the development of depressive disorders.

The nurse should identify that clients who are single are at an increased risk for the development of depressive disorders.

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?

Tell the client to talk less or risk being removed from the meeting.

Ask group members to discuss their feelings about this client's monopolizing behavior.

End the group meeting and take the client aside to discuss the disruptive behavior.

Focus on other group members and ignore the client who is doing all the talking.

ANS: Ask group members to discuss their feelings about this client's monopolizing behavior.

Rationale;

This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem- solving.

Threatening the client is not a therapeutic intervention.

This intervention is punitive to all members of the group, and it does not address the problem within the group setting.

Ignoring the client does not address the behavior and is unlikely to solve the problem.

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

"I will spend extra time at work to keep from feeling depressed."

"I will talk about my feelings with a close friend."

"I will be able to learn how to prevent my partner's attacks."

"I will use meditation instead of taking my antidepressant."

ANS: "I will talk about my feelings with a close friend."

Rationale:

Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

Spending extra time at work to keep from feeling depressed is a maladaptive coping mechanism. Examples of adaptive coping strategies include problem solving, learning new skills, and building self-esteem.

The client should not expect to prevent an attack from an abuser. The client should instead learn to identify warning signs and develop a safety plan to assist in escaping an unsafe environment.

While coping strategies, such as meditation, are often helpful in coping with feelings related to intimate partner violence, such as fear, anxiety, and depression, the client should continue to take medications as prescribed by the provider.

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?

Document the client's behavior every 8 hr.

Limit the client's fluid intake to 50 mL/hr.

Renew the prescription for the client every 4 hr.

Toilet the client every 4 hr.

ANS: Renew the prescription for the client every 4 hr.

Rationale;

The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

The nurse should document the client's behavior every 15 to 30 min while the client is in seclusion.

There is no indication to limit the client's fluid intake. The nurse should monitor the client every 15 to 30 min for hydration needs while the client is in seclusion.

The nurse should offer toileting to the client every 15 to 30 min while the client is in seclusion.

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?

Lansoprazole

Naproxen

Magnesium hydroxide

Phenylephrine

ANS: Phenylephrine

Rationale:

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.

Lansoprazole does not interact adversely with tranylcypromine.

Naproxen does not interact adversely with tranylcypromine.

Magnesium hydroxide does not interact adversely with tranylcypromine.

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM?

Shuffling gait

Hypotension

Decreased WBC count

Blurred vision

ANS: Shuffling gait

Rationale;

Benztropine is used to treat parkinsonism manifestations, such as shuffling gait.

Orthostatic hypotension is an adverse effect of conventional antipsychotic medications. However, it is not treated with benztropine.

Agranulocytosis is an adverse effect of conventional antipsychotic medications. However, it is not treated with benztropine.

Blurred vision is an adverse anticholinergic effect of conventional antipsychotic medications. However, it is not treated with benztropine.

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer.

Prompt the client to give a response.

Move on to the next client.

Offer the client a suggestion for a goal.

ANS: Allow the client time to formulate an answer.

Rationale;

Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question.

A client who has depression might have a slow response rate. Prompting can place pressure on the client.

Skipping the client might minimize the client's involvement in the group process and cause additional difficulty when answering the question.

A client who has depression is able to make decisions as necessary. Therefore, the nurse should not deny the client this ability to participate in the group therapy.

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?

Have the client participate in a morning aerobics group.

Encourage frequent rest periods throughout the day.

Provide a distraction such as television at night.

Offer the client hot chocolate at bedtime.

ANS: Encourage frequent rest periods throughout the day.

Rationale;

A client who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk of exhaustion.

The nurse should direct the client to areas with minimal activity to decrease stimulation.

A client who is experiencing mania requires a reduction in environmental stimuli to avoid continued agitation and tension. The nurse should provide the client with a quiet and low-stimulation environment to decrease excitability.

The nurse should integrate interventions to promote sleep, such as soft music, a quiet room, or warm milk. However, chocolate contains caffeine, a stimulant, which can hinder rest.

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

Increased creatine phosphokinase (CPK)

Increased low-density lipoproteins (LDL)

Decreased fasting blood glucose

Decreased aspartate aminotransferase (AST)

ANS: Increased creatine phosphokinase (CPK)

Rationale;

An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

LDL does not increase when a client is experiencing alcoholic cardiomyopathy.

Fasting blood glucose does not decrease when a client is experiencing alcoholic cardiomyopathy.

AST does not decrease when a client is experiencing alcoholic cardiomyopathy.

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?

Blurred vision

Orthostatic hypotension

Dry mouth

Acute dystonia

ANS: Acute dystonia

Rationale;

The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

Blurred vision is an anticholinergic effect that can occur with the use of chlorpromazine. However, benztropine is not used to relieve this adverse effect.

Dry mouth is an anticholinergic effect that can occur with the use of chlorpromazine. However, benztropine is not used to relieve this adverse effect.

Orthostatic hypotension can occur with the use of chlorpromazine. However, benztropine is not used to relieve this adverse effect.

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse?

Schedule the client for group therapy sessions.

Maintain consistent rules.

Provide frequent high-calorie snacks.

Avoid the use of value judgments.

ANS: Provide frequent high-calorie snacks

Rationale;

The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's need for adequate nutrition. Therefore, providing high-calorie snacks is the priority action for the nurse to take.

The nurse should incorporate group therapy in the client's care. However, this is not the priority action for the nurse to take.

The nurse should maintain consistent rules to minimize the client's manipulation of the staff. However, this is not the priority action for the nurse to take.

The nurse should avoid value judgments to minimize escalating mania. However, this is not the priority action for the nurse to take.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations.

The client is exhibiting echolalia.

The client reports loss of motivation.

The client is exhibiting blunted affect.

ANS: The client reports command hallucinations.

Rationale;

The nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a client who has schizophrenia. Command hallucinations can direct the client to harm themselves or others.

The nurse should identify that echolalia, or the repeating of another's words, is an expected manifestation of schizophrenia.

The nurse should identify that a loss of motivation, or avolition, is an expected manifestation of schizophrenia.

The nurse should identify that blunted affect, or a decreased emotional response, is an expected manifestation of schizophrenia.

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

"You might notice an increase in saliva while taking this medication."

"You might experience difficulties with sexual functioning while taking this medication."

"You should expect an improvement in symptoms of depression in 3 to 4 days."

"You may notice a temporary ringing in the ears when starting this medication."

ANS: "You might experience difficulties with sexual functioning while taking this medication."

Rationale;

Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs.

The nurse should instruct the client that improvement in mood takes 1 to 3 weeks or longer following the initiation of therapy with fluoxetine.

Fluoxetine does not cause tinnitus. The nurse should instruct the client that they might experience visual disturbances, but the medication does not affect the ears.

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?

"I put in extra hours at work so I won't think about drinking."

"I know that wine is good for my heart, so that's why I drink some each evening."

"I make up for my drinking by taking my partner on nice vacations."

"I am able to go to work every day, so I don't have a problem."

ANS: "I am able to go to work every day, so I don't have a problem."

Rationale:

By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder.

A client who consciously avoids thinking about uncomfortable feelings or thoughts is using the defense mechanism of suppression.

By relating their drinking every evening to their heart health, the client is using the defense mechanism of rationalization.

A client who attempts to make up for an undesirable act by doing something positive is using the defense mechanism of undoing.

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?

"I will avoid social events until my partner has completed treatment."

"It is important for me to focus my attention on my partner's addiction."

"I will not take charge of my partner's work responsibilities."

"I want my partner to promise to change addictive behaviors."

ANS: "I will not take charge of my partner's work responsibilities."

Rationale:

The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

The nurse should identify that avoiding social events is a codependent behavior.

The nurse should identify that focusing attention on the partner's substance use disorder is a codependent behavior.

The nurse should identify that requiring promises from the individual who has the substance use disorder is a codependent behavior.

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?

A 35-year-old client who has major depressive disorder

A 50-year-old client who has a blood alcohol level of 80 mg/dL

A 17-year-old client who lives with friends

A 65-year-old client who just received a dose of morphine

ANS: A 35-year-old client who has major depressive disorder

Rationale:

A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.

A client who is intoxicated cannot legally give informed consent.

Individuals younger than 18 years of age can only provide informed consent if they are married, pregnant, parents, or emancipated.

A client who has just received morphine, an opioid analgesic, is functionally incompetent due to the medication's effect on the CNS.

A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

"I am going to order a wheelchair for when I'm unable to walk."

"I am going to stop paying my bills since I won't be around much longer."

"I wish you would go take care of somebody who actually needs you."

"I am sure I'll be able to continue to care for myself without help."

ANS: "I am going to order a wheelchair for when I'm unable to walk."

Rationale;

The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates they have accepted the reality of their illness. This statement is an example of the acceptance, or final, stage of grief.

The client is verbalizing hopelessness, which is a manifestation of the depression stage of grief. Therefore, this statement does not indicate the client has accepted their illness.

The client is projecting their anger onto the nurse, which is a manifestation of the anger stage of grief. Therefore, this statement does not indicate the client has accepted their illness.

The client is denying the need for assistance in the future, which is a manifestation of the denial stage of grief. Therefore, this statement does not indicate the client has accepted their illness.

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%

Potassium 3.6 mEq/L (3.5 to 5 mEq/L)

Temperature 36.1° C (96.9° F)

Heart rate 54/min

ANS: Total body fat 8.7%

Rationale;

The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider.

Electrolyte levels significantly above or below the expected reference range are criteria for hospitalization. A client who has anorexia nervosa can experience hypokalemia. However, a potassium level of 3.6 mEq/L is within the expected reference range.

Criteria for hospitalization include a temperature less than 36° C (96.8° F).

Criteria for hospitalization is a heart rate less than 50/min during the daytime.

A nurse in an emergency department is caring for an adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis?

"They work so hard at ballet. Will they still be able to perform?"

"They're happier with their appearance now that they've lost some weight."

"They told me they were tired, so I did their chores for them today."

"They won't let me take the trash from their room. I'm concerned about what they have in there."

ANS: "They won't let me take the trash from their room. I'm concerned about what they have in there."

Rationale;

The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.

This statement provides little insight into the client's current psychological condition and indicates that the parent might be in denial.

This statement suggests that the parent is identifying positive effects of the eating disorder rather than understanding the negative health effects it has on the client.

This statement by the parent indicates that they are responding to the client's eating disorder with enabling behavior.

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?

Include a liquid supplement with meals.

Identify the client's trigger foods.

Allow the client at least 1 hr for each meal.

Weigh the client at bedtime each day.

ANS: Identify the client's trigger foods.

Rationale;

The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.

The nurse should include a liquid supplement for a client who is below their ideal body weight and might not be able to eat solid foods at first or might need the additional nutrition to gain weight.

The nurse should limit the client's meal times to about 30 min to prevent putting excessive focus on food.

The nurse should weigh the client immediately after they wake up and void and prior to oral intake. The nurse should weigh the client daily for the first week and then three times per week.

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?

"It appears as though you would like to open the door."

"You will feel more comfortable after you've been here for a while."

"It is okay to not want to be here."

"You really shouldn't be pushing on the door."

ANS: "It appears as though you would like to open the door."

Rationale;

This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

This statement is an example of nontherapeutic communication. It is falsely reassuring the client that everything will be fine. This type of communication minimizes the client's concerns and offers no constructive interventions.

This statement is an example of nontherapeutic communication. It assumes an understanding of the client's feelings and offers no constructive interventions.

This statement is an example of nontherapeutic communication. Disapproval of the client's actions can make the client defensive and offers no constructive interventions.

NGN INFO

A nurse on a mental health unit is caring for a recently admitted client.

Vital Signs

0800:

Blood pressure 110/78 mm Hg

Heart rate 76/min

Respiratory rate 18/min

Temperature 37° C (98.6° F)

1200:

Blood pressure 116/80 mm Hg

Heart rate 88/min

Respiratory rate 20/min

Temperature 38° C (100.4° F)

Medical History

22-year-old client admitted following episodes of hallucinations and delusions. Outpatient treatment has been ineffective. Client has been unable to maintain a job and friends have said the client has been acting different than usual. Family members have noticed that the client no longer maintains a clean and neat appearance.

For each potential assessment finding, click to specify if it is a positive or negative symptom of schizophrenia.

Withdrawal from social activities

Delusions of grandeur

Catatonia

Clang associations

Absence of intonation in speech

Alogia

ANS:

NEGATIVE SYMPTOMS ; Withdrawal from social activities

POSITIVE SYMPTOMS ; Delusions of grandeur

POSITIVE SYMPTOMS ; Catatonia

POSITIVE SYMPTOMS ; Clang associations

NEGATIVE SYMPTOMS ; Absence of intonation in speech

NEGATIVE SYMPTOMS ; Alogia

Rationale;

Delusions of grandeur, clang associations, and catatonia are consistent with positive symptoms of schizophrenia. Positive symptoms, the presence of symptoms that are not ordinarily present, include hallucinations, delusions, paranoia, and disorganized or bizarre thoughts, behaviors, or speech.

Absence of intonation in speech, alogia(difficulty in formulating thoughts and expressing them), and withdrawal from social activities are consistent with negative symptoms of schizophrenia. Negative symptoms, or the absence of something that should be present, include lack of goal-directed behavior, decrease in participation in social activities, and a flat affect.

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?

"Information regarding clients should remain confidential until after their death."

"Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states."

"As long as client identity is disguised, their health information can be shared between professionals on the internet."

"In the event a client threatens harm to others, medications can be administered without consent."

ANS: "In the event a client threatens harm to others, medications can be administered without consent."

Rationale;

The charge nurse should inform the participants that medications can be administered without consent if a client threatens harm to others. The nurse should always protect the health and safety of their clients, even when a client's safety is threatened by another client.

The reputation of a client can still be tarnished after death. Therefore, the charge nurse should inform the participants that any information which was kept confidential before a client's death should remain confidential after.

Laws vary for different states. Therefore, the charge nurse should instruct the participants to familiarize themselves with the requirements related to reporting neglect or maltreatment of clients within their state. In most states, failure to report suspected neglect, physical maltreatment, or exploitation of a disabled adult is a misdemeanor.

Information shared over the internet is not confidential and can be open to legal subpoenas. Therefore, clients could be identified and could initiate lawsuits against the individual who shared the information. The charge nurse should inform the participants to avoid sharing any client information on the internet.

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?

Clang association

Word salad

Neologism

Echolalia

ANS: clang association

Rationale;

The nurse should document that the client's speech uses clang associations, which often rhyme or contain a string of words that can have a similar sound.

In word salad, words are completely meaningless and disorganized. This client's speech pattern is not word salad.

Neologism consists of words that are made up by the client. This client's speech pattern does not contain neologisms.

In echolalia, the client repeats the words of another person. This client's speech pattern is not echolalia.

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?

Obtain the weight of a client who has bipolar disorder and is experiencing mania.

Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days.

Monitor the cardiovascular status of a client who is experiencing serotonin syndrome.

Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

ANS: Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

Rationale;

A client who has borderline personality disorder is at risk for self-mutilation, such as cutting, self-inflicted wounds, scratching, or picking at wounds. It is within the LPN's scope of practice to change the dressing, cleanse the wound, and collect data regarding the healing of the wound.

A client who has bipolar disorder and is experiencing mania can exhibit weight loss caused by decreased caloric intake and hyperactivity. Obtaining the weight of a client is within the range of function of the assistive personnel.

A client who has anorexia nervosa severely restricts nutritional intake over a fear of gaining weight. Even if the client does eat, they are at risk for purging following the meal. It is important to stay with the client throughout the meal and observe them for at least 1 hr after eating to ensure the meal is eaten and not purged. Assessing the nutritional intake of a client who has anorexia nervosa is within the scope of practice for an RN.

Serotonin syndrome(too much serotonin causes signs and symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever and seizures) is a life-threatening adverse reaction associated with selective serotonin reuptake inhibitors. A client who is experiencing serotonin syndrome is unstable. Therefore, the registered nurse should provide care and monitoring to this client.

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?

"You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat."

"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

"You don't want to look at yourself because you think you are fat."

"You and I can work together to overcome your fears of gaining weight."

ANS: "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

Rationale;

The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

The nurse is using the therapeutic technique of focusing in this statement.

The nurse is using the therapeutic technique of restating in this statement.

The nurse is using the therapeutic technique of suggesting collaboration in this statement.

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?

Increased confusion

Sleep disturbances

Cluttered environment

Inappropriate dress

ANS: Inappropriate dress

Rationale;

Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.

Increased confusion is an indicator of psychological abuse.

Sleep disturbances are an indicator of psychological abuse.

A cluttered environment is not an indicator of neglect.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

Sedation

Rhinorrhea

Bradycardia

Hypothermia

ANS: Rhinorrhea

Rationale;

The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea(runny nose)and flu-like manifestations such as yawning, sneezing, and abdominal pain.

The nurse should expect the client experiencing opioid withdrawal to have insomnia.

The nurse should expect the client experiencing opioid withdrawal to have tachycardia.

The nurse should expect the client experiencing opioid withdrawal to have hyperthermia.

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash.

The client's town was hit by a tornado.

The client's youngest child is leaving for college.

The client is ambivalent about their upcoming retirement.

ANS: The client recently lost a grandparent in a motor vehicle crash.

Rationale;

The client experiences a situational crisis when an unexpected event occurs.

The client experiences an adventitious crisis when an external disaster occurs.

The client experiences a maturational crisis during a natural life event.

The client experiences a maturational crisis during a natural life event.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?

Raise the pitch of the voice when speaking to the client.

Begin the interview by explaining the plan of care.

Interview the client in a private setting.

Ask the client to complete a detailed questionnaire.

ANS: Interview the client in a private setting.

Rationale;

The nurse should interview clients in a private place when asking questions regarding client health.

The nurse should use a lower pitch of voice when speaking because older adult clients are typically able to hear words that are spoken with a lower pitch.

The nurse should begin the interview by asking the client to identify their needs and concerns. This data is then used to create a personalized plan of care.

The nurse should limit the number of items on a questionnaire when gathering data from an older adult client.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Orient the client to person, place, and time.

Assist the client with deep-breathing exercises.

Calm the client by using therapeutic touch.

Have the client sit alone in a quiet room.

ANS: Assist the client with deep-breathing exercises.

Rationale;

Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

A client who is experiencing a panic attack is generally not disoriented.

Therapeutic touch is not intended to de-escalate panic in a client who is anxious.

It is recommended that the nurse stay with a client who is experiencing panic anxiety to ensure the client's safety.

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?

Complete documentation about the client's status every hour while they are in restraints.

Maintain the client in restraints for a minimum of 4 hr.

Apply restraints when other means of managing the client's behavior have failed.

Request that the provider assess the client within 8 hr of the application of restraints.

ANS:

Apply restraints when other means of managing the client's behavior have failed.

Rationale;

According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.

The nurse should document the client's status, including behavior and vital signs, and address the client's physical and safety needs every 15 min.

Restraints should be removed as soon as the client is able to follow instructions, control their behavior, and is no longer at risk for injuring themselves or others. The maximum amount of time an adult client should remain in restraints is 4 hr.

The use of mechanical restraints requires a provider's prescription. In emergent cases, the prescription can be obtained after restraints have been applied. However, the provider must evaluate the client within 1 hr of the initiation of restraints.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

Tell the client that the voices do not really exist.

Touch the client to help reduce feelings of anxiety.

Instruct the client to go to a quiet room when the voices start talking.

Ask the client what the voices are saying.

ANS: Ask the client what the voices are saying.

Rationale;

It is important for the nurse to ask the client directly about the hallucinations to determine if the client or others are at risk for injury.

The nurse should avoid negating the client's hallucination.

The nurse should avoid touching the client without first asking for the client's permission. Touching the client violates their personal space and can increase, rather than decrease, feelings of anxiety.

The nurse should instruct the client to listen to music or use other auditory distractions when the voices are talking.

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?

Offering self

Use of silence

Attention to body language

Reflection of feelings

ANS: Attention to body language

Rationale;

Use of active listening involves identifying verbal and nonverbal communication by the client, which includes attention to body language.

The nurse uses offering self therapeutic technique to demonstrate genuine interest in the client.

The nurse uses use of silence therapeutic technique to demonstrate willingness to wait for the client's response.

The nurse uses reflection of feelings therapeutic technique to encourage the client to acknowledge their feelings.

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 school-age child who has bruises on the knees

An older adult client who is bedbound and has a stage IV pressure ulcer

An adolescent who has a vaginal candida infection

A young adult who is pregnant and has a sprained ankle

ANS: An older adult client who is bed-bound and has a stage IV pressure ulcer

Rationale;

A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

Bruises on the knees is an expected finding for a school-age child due to minor injuries and falls during this stage of life.

Vaginal yeast infections can occur for an adolescent and are not an indicator of abuse.

The physiological change in the center of gravity during pregnancy is a common cause for losing balance, tripping, and spraining an ankle.

NGN INFO

A nurse in the emergency department (ED) is admitting a client who was dropped off at the front door.

Nurses' Notes

0200:

Client is difficult to arouse, is unable to report on recent events, and is unaware of arrival to ED.Evidence of emesis on clothing. Client reports nausea and has vomited two times since arrival.

Odor of alcohol on breath and clothing.Client connected to cardiopulmonary monitoring. Alarms set.

0210:Provider updated and prescriptions received.

Graphic Record

0200:

Temp 35.6° C (96° F)

HR 62

RR 11

BP 90/56 mm Hg

SpO2 95% RA

Weight 74.8 kg (165 lb)

Glasgow coma scale (GCS) 13 (3 to 15)

Diagnostic Results

0230:

Blood alcohol concentration (BAC) 340 mg/dL (0 to 50 mg/dL)

Blood glucose level 82 mg/dL (74 to 106 mg/dL)

WBC count 7,400/mm3 (5,000 to 10,000/mm3)

Provider's Prescriptions

0215:

Obtain blood alcohol concentration (BAC).

Obtain blood glucose level.

Obtain WBC count.

Progress Report

0230:

Prior medical record obtained and reviewed.Client has a history of major depressive disorder and has had two prior suicide attempts.Currently lives at a halfway house in town.Last hospitalization was 3 months ago for phenelzine toxicity. Client was changed to selegiline transdermal prior to discharge. Weight at time of discharge was 83.5 kg (184 lb).

The nurse is assessing the client.

Select the 5 findings that require follow-up.

Oxygen saturation

WBC count

Blood glucose level

BAC

Level of consciousness (LOC)

Nausea and vomiting

Temperature

Respiratory rate

GSC score

ANS:

BAC

Level of consciousness (LOC)

Nausea and vomiting

Temperature

Respiratory rate

Rationale;

-A BAC of 340 mg/dL indicates alcohol toxicity. This value indicates a critical level.

-A client who has an altered LOC following alcohol ingestion might be experiencing alcohol toxicity

-For a client who has ingested alcohol, nausea and vomiting can be an indication of alcohol toxicity, which can result in an alteration in vital signs.

-The client can experience a reduction of body temperature as a manifestation of alcohol toxicity.

-A respiratory rate of 11/min is below the expected reference range and can indicate alcohol toxicity in the client.

-Hypoglycemia can mimic the manifestations of alcohol toxicity. However, this client's blood glucose level is 82 mg/dL, which is within the expected reference range.

-An oxygen saturation of 95% is within the expected reference range.

-The GCS can measure neurological impairment, which can mimic alcohol toxicity. The client has a score of 13, which indicates the there is no neurological impairment.

-When assessing a client for alcohol toxicity, other health conditions should be considered. A WBC count of 7,400 is within range and indicates there is no infection in the body.

BASED OF NGN INFO IN PREVIOUS SLIDE:

For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major depressive disorder. Each finding may support more than one disease process.

Nausea and vomiting

Respiratory Rate

Marital Status

Level of consciousness (LOC)

Weight change

ANS:

ALCOHOL TOXICITY ; Nausea and vomiting

ALCOHOL TOXICITY ; Respiratory Rate

ALCOHOL TOXICITY & MAJOR DEPRESSIVE DISORDER ; Marital Status

ALCOHOL TOXICITY ; Level of consciousness (LOC)

MAJOR DEPRESSIVE DISORDER ; Weight change

Rationale;

Weight change is consistent with major depressive disorder. Clients who have major depressive disorder can experience significant weight loss. A 5% or greater loss in weight in a month is considered significant.

Level of consciousness (LOC) is consistent with alcohol toxicity. Alcohol is a psychotropic drug and, when ingested at an excessive volume, can affect a client's mood, behavior, and consciousness.

Nausea and vomiting is consistent with alcohol toxicity. A BAC of 150 mg/dL can result in nausea and vomiting.

Mental status is consistent with alcohol toxicity and major depressive disorder. Alcohol is a psychotropic drug and can result in decreased thinking ability, impaired judgment, and slowed thinking when ingested. A client who has a history of major depressive disorder can display a diminished ability to think or concentrate and is often indecisive.

Respiratory rate is consistent with alcohol toxicity. A client who has a BAC of 300 mg/dL can exhibit a decrease in body temperature, blood pressure, and respiratory rate.

NGN INFO

A nurse in the emergency department (ED) is caring for a client who has alcohol toxicity.

0200:

Client is difficult to arouse, is unable to report on recent events, and is unaware of arrival to ED.

Evidence of emesis on clothing. Client reports nausea and has vomited two times since arrival.

Odor of alcohol on breath and clothing.

Client connected to cardiopulmonary monitoring. Alarms set.

0210:

Provider updated and prescriptions received.

0330:

Client has had no further emesis.

Client woke up and is becoming very agitated, irritable, and anxious.

Client requests water to drink.

Client is still unable to remember recent events or how they arrived at the ED, resulting in fearful behavior.

Hand tremors noted.

0200:

Temp 35.6° C (96° F)

HR 62

RR 11

BP 90/56 mm Hg

SpO2 95% RA

Weight 74.8 kg (165 lb)

Glasgow coma scale (GCS) 13 (3 to 15)

0330:

Temp 37.7° C (99.9° F)

HR90

RR 20

BP 100/64 mm Hg

SpO2 96% RA

Progress Report

0230:

Prior medical record obtained and reviewed.

Client has a history of major depressive disorder and has had two prior suicide attempts.

Currently lives at a halfway house in town.

Last hospitalization was 3 months ago for phenelzine toxicity. Client was changed to selegiline transdermal prior to discharge.

Weight at time of discharge was 83.5 kg (184 lb).

Complete the following sentence by choosing from the lists of options.

The client is at risk for developing __1__ as evidenced by the client's __2__.

Drop 1

Respiratory distress

alcohol withdrawal

aspiration

Drop 2

HR

Mental status

pulse oximetry

ANS:

1. alcohol withdrawal

2. mental status

Rationale;

Dropdown 1

-The client had clear evidence of alcohol toxicity, including a BAC of 340 mg/dL. There has been no further alcohol intake since admission to the facility, increasing the client's risk for developing alcohol withdrawal syndrome.

Respiratory distress is incorrect. The client has an oxygen saturation of 96%, which is within the expected reference range. The client's respiratory rate has improved from 11/min to 20/min, so the risk of respiratory distress has resolved.

Aspiration is incorrect. This client is no longer displaying risk factors for aspiration. Level of consciousness (LOC) is no longer depressed from the alcohol toxicity, and the client is no longer vomiting.

Dropdown 2

-A client who has had an abrupt cessation of alcohol intake will exhibit hand tremors and mental status changes, including agitation, irritability, and anxiety. These are all manifestations of alcohol withdrawal syndrome.

HR is incorrect. Upon awakening, the client's heart rate has increased to 90/min, which is still within the expected reference range of 60 to 100/min.

SpO2 is incorrect. This client's SpO2 is within range and does not indicate

BASED ON NGN INFO IN PREVIOUS FLASHCARD

For each of the provider's potential prescriptions, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Obtain an Alcohol Use Disorders Identification Test (AUDIT).

Administer an anti- anxiety medication.

Initiate IV access.

Wake the client every 30 min for neurological assessment.

Monitor vital signs every 30 min.

Obtain CT scan of brain.

ANS:

NONESSENTIAL ; Obtain an Alcohol Use Disorders Identification Test (AUDIT).

ANTICIPATED ; Administer an anti- anxiety medication.

ANTICIPATED ; Initiate IV access.

CONTRAINDICATED ; Wake the client every 30 min for neurological assessment.

ANTICIPATED ; Monitor vital signs every 30 min.

NONESSENTIAL ; Obtain CT scan of brain.

RATIONALE;

CT scan of brain is nonessential. Although a head injury can mimic manifestations of alcohol withdrawal delirium, there is no indication that the client has had a head injury and requires a CT scan.

Monitor vital signs every 30 min is anticipated. Vital signs should be monitored frequently to continually assess the client for peripheral circulatory collapse that can occur with alcohol withdrawal.

Obtain an Alcohol Use Disorders Identification Test (AUDIT) is nonessential. This screening tool is a self-reporting tool to assist a health care provider with gaining information, which can be used to develop a plan of care. This is not an appropriate prescription for the client at this time, as they are experiencing psychotic manifestations of acute alcohol withdrawal.

Initiate IV access is anticipated. Treatment for alcohol withdrawal syndrome requires sedation to prevent seizure activity and circulatory collapse. This is best accomplished for the client via the IV route.

Administer an anti-anxiety medication is anticipated. The client is displaying agitation and reporting hallucinations and therefore requires anti- anxiety medication.

Wake the client every 30 min for neurological assessment is contraindicated. The treatment plan for this client should include sedation to encourage rest. The client does not require a neurological examination every 30 min.

BASED ON NGN INFO IN PREVIOUS FLASHCARD

plus following info

0400:

Client has become increasingly agitated and reports visual hallucinations, stating there are "bad people hiding in the room."

Tremors have increased, and client is perspiring profusely.

Client refuses to sit down and is trying to seek out the "people hiding in the room."

Client admits that the previous evening, they "planned to empty out the medicine cabinet and take all the pills in there, but I guess I passed out first."

Client states, "My life is such a mess; I can't even die right. I really don't have any reason to live."

Nurse remains with client. Provider notified.

0400:

Temperature 38.3° C (101° F)

Heart rate 122/min

Respiratory rate 26/min

Blood pressure 164/82 mm Hg

Complete the following sentence by using the lists of options.

The nurse should first initiate __1__ followed by __2__

drop 1

initiate suicide precautions

repeat blood glucose level

monitor vital signs every 30 mins

drop 2

administering acetaminophen

administering diazepam

initiating IV access

ANS:

1. initiate suicide precaution

2. initiating IV access

Rationale;

Dropdown 1

Initiate suicide precautions is correct. The greatest risk to this client is self- injury. Therefore, the first action the nurse should take is to initiate suicide precautions. The client has a history of self-injury and indicates that they have had recent thoughts of harming themselves.

Repeat the blood glucose level is incorrect. Repeating the blood glucose level is important for monitoring the glycogen stores of the client. However, there is another action the nurse should take !rst.

Monitor vital signs every 30 min is incorrect. The nurse should monitor the vital signs at least every 30 min. However, there is another action the nurse should take first.

Dropdown 2

Administering acetaminophen is incorrect. Hyperthermia is a complication of alcohol withdrawal syndrome. The client's temperature has steadily risen and should be addressed and reduced. However, the nurse must initiate IV access before the medication can be administered.

Administering diazepam is incorrect. Diazepam is used during alcohol withdrawal to allow the client to relax and rest. However, the nurse must initiate IV access before the medication can be administered.

Initiating IV access is correct. The client has multiple manifestations of alcohol withdrawal syndrome. The primary treatment goal is to provide sedation and IV fluids. Therefore, the nurse must initiate the IV access before these medications can be administered.

BASED ON NGN INFO IN PREVIOUS FLASHCARD

plus following info

1230:

Client slept with minimal disruption for 8 hr.

Client is no longer perspiring, and tremors have decreased. Upon awakening, client is withdrawn and quiet. After questioning, the client does recall drinking "a lot of liquor and trying other types of alcoholic beverages." Client is still unable to recall the trip to the facility.

1230:

Temperature 38° C (100.4° F)

Heart rate 95/min

Respiratory rate 22/min

Blood pressure 124/62 mm Hg

The nurse is evaluating the client after interventions for alcohol withdrawal syndrome have been implemented. Which of the following findings indicate a positive response to therapy? (Select all that apply.)

Blood pressure

Tremors

Unable to recall the trip to the facility

Withdrawn and quiet upon awakening

Temperature

Heart rate

Respiratory rate

Slept with minimal disruption for 8 hr

ANS:

Slept with minimal disruption for 8 hr

Heart rate

Respiratory rate

Blood pressure

Tremors

Rationale;

Slept with minimal disruption for 8 hr is correct. One of the major goals for a client who is experiencing alcohol withdrawal syndrome is sedation and rest. The client slept for 8 hr, indicating a positive response to therapy.

Blood pressure is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's blood pressure has decreased from 164/82 mm Hg to 124/62 mm Hg, indicating a positive response to therapy.

Withdrawn and quiet upon awakening is incorrect. These are manifestations of the client's major depressive disorder and can increase the risk for suicidal ideation.

Temperature is incorrect. A client who is experiencing alcohol withdrawal manifests an elevation of vital signs. The client's temperature has been greater than 37.2° C (99° F).

Unable to recall the trip to the facility is incorrect. Memory blackouts are a manifestation of alcohol withdrawal syndrome. The client's memory remains impaired and unable to recall

recent events.

Heart rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's heart rate has dropped from 122/min to 95/min, indicating a positive response to therapy.

Tremors is correct. Tremors are a manifestation of alcohol withdrawal syndrome. The client's decreased tremor activity is an indication of a positive response to therapy.

Respiratory rate is correct. A client who is experiencing alcohol withdrawal syndrome manifests an elevation of all vital signs. The client's respiratory rate has dropped from a high of 26/min to 22/min, indicating a positive response to therapy.

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

Ask the client to identify the bomb in the room.

Initiate disaster protocols per facility policies and procedures.

Assess the client for evidence of a perceptual disturbance.

Convince the client that there is no bomb in their room.

ANS: Assess the client for evidence of a perceptual disturbance.

Rationale;

The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli, also known as experiencing illusions.

Asking the client to identify the bomb in the room is an inappropriate action because the nurse is responding as if the hallucination is real.

Without evidence of a disaster on a mental health unit, it is inappropriate to initiate disaster protocols.

Trying to convince the client that there is not a bomb in their room negates the client's experience.

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Sore throat

Photophobia

Hand tremors

Constipation

ANS: Hand Tremors

Rationale;

Fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs, causing the client to stop taking the medication.

A sore throat is not an expected adverse effect of lithium.

Photophobia is not an expected adverse effect of lithium.

Diarrhea is an early manifestation of lithium toxicity.

NGN INFO

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.

Vital Signs

6/4/XX (Visit 1):

Blood pressure 100/64 mm Hg

Heart rate 62/min

Respiratory rate 16/min

Temperature 36.3° C (97.3° F)

Oxygen saturation 98%

6/18/XX (Visit 2):

BP 102/66 mm Hg

HR 56

RR 18/min

Temperature 36.4° C (97.5° F)

Oxygen saturation 99%

Diagnostic Results

Visit 1:

ECG Normal sinus rhythm

Cholesterol 196 mg/dL

Platelet count 155,000/mm3 (150,000 to 400,000/mm3)

Visit 2:

ECG QT prolongation

Cholesterol 238 mg/dL

Platelet count 140,000/mm3 (150,000 to 400,000/mm3)

Nurse Note

Client reports taking laxatives daily and inducing vomiting 3 or 4 days per week.

Client states, "I have always been a nervous person, even as a kid. I feel like I need to be perfect, or everyone will think I'm a complete failure. I can't believe I let myself gain this much weight - I look awful."

BMI 16.8.

Visit 2:

Client reports no longer taking laxatives. Client also reports inducing vomiting most days and new onset of hematemesis. Petechiae noted on face and sclera. Client states, "I started therapy and have had two sessions so far. I also got some exercise equipment and have started working out twice a day." BMI 16.4.

Click to highlight the information in the client's medical record that indicate the client's condition is deteriorating. To deselect information, click on the information again.

QT prolongation

Exercise regimen

Hematemesis

Temperature

Laxative use

BMI

ANS:

QT prolongation

Exercise regimen

Hematemesis

BMI

Rationale;

-The finding of QT prolongation in the client's ECG during the second visit reveals cardiac complications of anorexia nervosa. Changes in electrolyte levels can shorten or prolong the QT interval. This is an indication of deteriorating.

-The client's purchase of exercise equipment and working out twice a day is a new manifestation of anorexia nervosa. This is an indication of deteriorating.

-New onset of hematemesis might be caused by esophageal irritation or ulceration due to the increase in the frequency of induction of vomiting. Continued induction of vomiting can cause esophageal rupture. Therefore, hematemesis is an indication of deteriorating.

-The client's temperature has remained within the expected reference range. A decrease in body temp with cool skin is an indication of deteriorating.

-The client's cessation of the use of laxatives is an indication of improving.

-The client's BMI decreased between visits, which indicates the client is continuing to lose weight. This is an indication of deteriorating.

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?

Calling family members

Spending time alone

Giving away possessions

Excessive crying

ANS: Giving away possessions

Rationale;

Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team.

The nurse should report that the client is calling family members to indicate that the client has a support system. However, another behavior is the priority.

The nurse should report that the client is spending time alone to indicate the client is withdrawn from others. However, another behavior is the priority.

The nurse should report that the client is crying excessively to indicate the client is showing signs of depression. However, another behavior is the priority.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Confront the staff member.

Encourage the client to report the incident.

Document the incident in the client's health record.

Report the occurrence to the charge nurse.

ANS: Report the occurrence to the charge nurse.

Rationale;

It is the responsibility of the charge nurse and the nurse manager to confront the staff member about the derogatory comments made to the client.

It is not the responsibility of the nurse to discipline other staff members.

This action takes the responsibility away from the nurse who has overheard the comments.

The incident should not be documented in the client's health record.

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?

An adolescent family member who questions parental authority

A family with three generations in the same household

Older children who are responsible for their younger siblings

Two adults and their children from prior relationships in the same household

ANS: Older children who are responsible for their younger siblings

Rationale;

This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.

An adolescent who questions parental authority is demonstrating appropriate behavior for developmental age.

This scenario occurs in many households, and it is not an indication of a boundary issue.

This is an example of a blended family, and it is not an indication of a boundary issue.

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?

Move the client to a room near the nurses' station.

Limit visitors until the client is oriented to the environment.

Tell the client that their partner is deceased.

Talk with the client about activities they enjoyed with their partner.

ANS: Talk with the client about activities they enjoyed with their partner.

Rationale;

Talking about positive experiences can help distract the client from their disorientation.

When caring for a client who has dementia, avoid placing the client in unfamiliar settings whenever possible.

Family members should be encouraged to interact with the client regardless of the client's state of dementia.

Confrontation should not be used for a client who is disoriented.

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?

Decrease distractions during meal times.

Provide positive feedback when the child completes a task.

Clearly identify consequences for unacceptable behavior.

Remove unnecessary equipment from the child's surroundings.

ANS: Remove unnecessary equipment from the child's surroundings.

Rationale;

The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

The nurse should decrease distractions during meal times for a child who has ADHD. However, this intervention does not address the greatest risk to the child and therefore is not the priority intervention.

The nurse should provide positive feedback for task completion for a child who has ADHD. However, this intervention does not address the greatest risk to the child and therefore is not the priority intervention.

The nurse should clearly identify consequences for unacceptable behavior for a child who has ADHD. However, this intervention does not address the greatest risk to the child and therefore is not the priority intervention.

NGN INFO

A nurse on a mental health unit is admitting a client who has bipolar disorder.

Vital Signs

Day 1, admission at 2000:

Blood pressure 158/98 mm Hg

Heart rate 104/min

Respiratory rate 20/min

Temperature 37.4° C (99.4° F)

SpO2 98%

Day 2, 1000:

Blood pressure 158/98 mm Hg

Heart rate 134/min

Respiratory rate 24/min

Temperature 37.7° C (99.9° F)

SpO2 97%

Medical History

Day 1, admission at 2000:

Client was diagnosed with bipolar I disorder 3 years ago.

Client was hospitalized for mania at time of diagnosis. Manages condition with medication and outpatient treatment.

Client had a tonsillectomy at 4 years of age.

Was hospitalized for pneumonia 5 years ago.

Nurses' Notes

Day 1, 2000 admission note:

Client talkative during admission interview. Tapping feet, frequently !dgeting in chair. Occasionally laughs inappropriately. Client wearing jeans, two sweatshirts, knit stocking cap, heavy socks, and boots despite outdoor temperature of 26.7° C (80.1° F). Client reports they're not sure when they last took their medication and states, "I've been doing !ne so thought I would see how I feel without it." Client unsure when they last ate but denies feeling hungry.

Day 2, 1000:

Client rapidly pacing throughout room, unable to sit down or stand still. Exhibiting pressured speech and #ight of ideas. Speaking in a loud voice, moving arms and hands around dramatically while speaking. Client easily distracted, has di$culty focusing on conversation and answering questions. Client's face is #ushed, and they are diaphoretic.

Client exhibits persecutory delusions, stating, "The government listens to all my phone calls. They're out to get me!"

Client has not eaten since admission, has had 190 mL #uid intake. Voided 220 mL dark yellow urine. Slept 1 hr during the night in several short naps.

Diagnostic Results

Day 2, 0700:

Lithium 0.1 mEq/L (0.8 to 1.2 mEq/L)

Complete the following sentence by using the list of options.

The first action the nurse should take is to address the client's __1__due to the client's__2__ .

ANS:

1. cardiovascular injury

2. constant psychomotor activity

Rationale;

When prioritizing hypotheses, the nurse should identify the greatest risk to the client is cardiovascular injury due to constant psychomotor activity. The client is pacing, moving arms and hands around dramatically, and is unable to sit still. This can increase the client's blood pressure and heart rate, which can indicate unexpected cardiovascular findings.

NGN INFO

A nurse is caring for a client who has anorexia nervosa.

Vital Signs

Day 1

Blood pressure 90/60 mm Hg

Heart rate 54/min

Respiratory rate 16/min

Temperature 36.1° C (97° F)

Day 14:

Blood pressure 88/58 mm Hg

Heart rate 64/min

Respiratory rate 16/min

Temperature 36.1° C (97° F)

Diagnostic Results

Day 1:

Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)

Sodium 150 mEq/L (136 to 145 mEq/L)

BUN 35 mg/dL (10 to 20 mg/dL)

Glucose 78 mg/dL (74 to 106 mg/dL)

Day 14:

Potassium 3.7 mEq/L (3.5 to 5.0 mEq/L)

Sodium 143 mEq/L (136 to 145 mEq/L)

BUN 18 mg/dL (10 to 20 mg/dL)

Glucose 76 mg/dL (74 to 106 mg/dL)

Physical Examination

Day 1:

• BMI 16.8

• Yellow sclera

• Skin is cool

• Reports no bowel movement for 5 days

• 1+ peripheral edema

• Reports exercising 2 hr per day

Day 14:

• BMI 17.8• Yellow sclera

• Skin is warm

• Reports last bowel movement 1 day ago

• 1+ peripheral edema

• Reports exercising 2 hr per day

A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? (Select all that apply.)

Bowel movement

BUN

Sodium

Glucose

Heart rate

Skin temperature

Peripheral edema

Potassium

BMI

Blood pressure

ANS:

Bowel movement

BUN

Sodium

Heart Rate

Skin temperature

Potassium

BMI

Rationale;

-The client's constipation has improved based on the increased frequency of their bowel movements.

-Clients who have anorexia nervosa usually have an increased BUN. The client's BUN level is now within range.

-Clients who have anorexia nervosa can have hypernatremia related to dehydration. The client's sodium level is now within range.

-Clients who have anorexia nervosa usually have bradycardia. The client's HR is now within the expected range.

-Clients who have anorexia nervosa usually have cool skin. After 2 wks, the client's skin is warm

-Clients who have anorexia nervosa usually have hypokalemia. The client's potassium level is now within range.

-Clients who have anorexia nervosa usually have a BMI of less than 17. The client's initial BMI indicates moderate anorexia nervosa while the current BMI indicates mild anorexia nervosa.

-The client's glucose level has remained within range, which does not indicate an improvement

-The client's peripheral edema remains unchanged, which does not indicate an improvement in the client's condition.

-The client's blood pressure still indicates hypotension, which does not indicate an improvement in the client's condition.