Review ATI RN Mental health 2019 NGN II

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ATI RN Mental health 2019 NGN II

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Total Questions : 70

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Question 1:

A nurse is caring for a client who has schizophrenia and is taking clozapine.
Which of the following findings is the priority for the nurse to report to the provider?

A. Random blood glucose 130 mg/dL. B. Nausea. C. Heart rate 104/min. D. Sore throat.

Answer and Explanation

Choice A:

Random blood glucose 130 mg/dL is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 70 to 110 mg/dL, but it is not indicative of a serious condition such as diabetes mellitus or hyperglycemia. Clozapine can cause hyperglycemia in some patients, but this is usually a chronic effect that develops over months or years of treatment. Therefore, a single random blood glucose measurement of 130 mg/dL is not a cause for immediate concern or intervention. The nurse should monitor the client’s blood glucose levels regularly and educate the client on the signs and symptoms of hyperglycemia, such as increased thirst, urination, hunger, and fatigue. The nurse should also encourage the client to maintain a healthy diet and exercise regimen to prevent or manage hyperglycemia.

Choice B:

Nausea is not a priority finding for the nurse to report to the provider. Nausea is a common side effect of clozapine that usually occurs during the initial phase of treatment or after a dose increase. It is usually mild and transient and can be managed by taking the medication with food or water, using antiemetics, or reducing the dose if necessary. Nausea does not indicate a serious or life-threatening adverse reaction to clozapine, unless it is accompanied by other symptoms such as vomiting, abdominal pain, jaundice, or fever. The nurse should assess the client’s nausea and provide supportive care and education on how to cope with it.

Choice C:

Heart rate 104/min is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 60 to 100 beats per minute, but it is not indicative of a serious condition such as tachycardia or cardiac arrhythmia. Clozapine can cause orthostatic hypotension, bradycardia, syncope, and cardiac arrest in some patients, but these are rare and serious adverse effects that require immediate medical attention. Therefore, a single heart rate measurement of 104/min is not a cause for immediate concern or intervention. The nurse should monitor the client’s vital signs regularly and educate the client on the signs and symptoms of orthostatic hypotension, such as dizziness, lightheadedness, or fainting when changing positions. The nurse should also advise the client to rise slowly from a lying or sitting position, avoid alcohol and other substances that can lower blood pressure, and drink plenty of fluids to prevent dehydration.

Choice D:

Sore throat is a priority finding for the nurse to report to the provider. Sore throat is a sign of infection, inflammation, or irritation of the throat, which can be caused by various factors such as viruses, bacteria, allergens, or irritants. However, in a client who is taking clozapine, sore throat can also indicate a serious and potentially fatal adverse effect of the medication: severe neutropenia. Neutropenia is a condition in which the number of neutrophils, a type of white blood cell that fights infection, is abnormally low. This increases the risk of developing serious and life-threatening infections, especially in the mouth, throat, and respiratory tract. Clozapine can cause neutropenia in some patients, especially during the first 18 weeks of treatment, and it is the most common reason for discontinuing the medication. Therefore, any client who is taking clozapine and develops a sore throat should be evaluated by the provider as soon as possible to rule out neutropenia and initiate appropriate treatment if needed. The nurse should also educate the client on the importance of regular blood tests to monitor the absolute neutrophil count (ANC) and the signs and symptoms of infection, such as fever, chills, weakness, or sore throat. The nurse should also instruct the client to avoid contact with people who are sick, practice good hygiene, and report any signs of infection immediately.

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Question 2:

A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.”. The client has tachycardia and hypertension.
The nurse should suspect acute toxicity of which of the following substances?

A. Alcohol. B. Heroin. C. Opium. D. Cocaine.

Answer and Explanation

Choice A:

Alcohol toxicity typically presents with symptoms such as confusion, slurred speech, and ataxia, rather than paranoia ("People are out to get me"). While alcohol can cause increased heart rate and blood pressure, it is not the most likely substance to cause these symptoms in the context of paranoia.

Choice B:

Heroin toxicity is characterized by central nervous system depression, pinpoint pupils, and respiratory depression, which do not align with the client's symptoms of paranoia, tachycardia, and hypertension.

Choice C:

Opium toxicity shares some similarities with heroin toxicity, including central nervous system depression and pinpoint pupils. It is not typically associated with paranoia or the vital sign changes described in the scenario.

Choice D:

Cocaine toxicity is the most likely cause of the client's symptoms. Cocaine can lead to paranoia, tachycardia, and hypertension. The combination of these symptoms suggests acute cocaine toxicity, making it the priority concern for the nurse. Prompt intervention is necessary to address the potential life-threatening effects of cocaine toxicity.

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Question 3:

A nurse is receiving change-of-shift report for four clients.
Which of the following clients should the nurse see first?

A. A client who has bipolar disorder and is speaking loudly. B. A client who has schizophrenia and is experiencing olfactory hallucinations. C. A client who is taking clozapine and reports a sore throat. D. A client who is taking lithium and reports weight gain.

Answer and Explanation

Choice A:

A client with bipolar disorder who is speaking loudly is displaying a manic symptom, which may require attention but is not the highest priority among the options. It does not pose an immediate risk to the client's physical health.

Choice B:

A client with schizophrenia experiencing olfactory hallucinations may be distressed, but this is not an immediate physical health concern. It may require attention but is not the highest priority.

Choice C:

A client taking clozapine who reports a sore throat should be seen first. Clozapine is associated with a risk of agranulocytosis, a severe condition that can lead to a dangerously low white blood cell count. A sore throat can be an early sign of infection, and in the context of clozapine use, it is crucial to assess and monitor for agranulocytosis promptly. This condition is life-threatening and requires immediate attention to prevent complications. .

Choice D:

Weight gain is a potential side effect of lithium, and while it should be monitored and addressed, it is not a critical finding that requires immediate attention.

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Question 4:

A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm.
Which of the following actions should the nurse take?

A. Withhold the next dose of the medication. B. Ask the client about a recent change in laundry detergent. C. Apply hydrocortisone cream on the client's rash. D. Explain that the medication causes a temporary rash.

Answer and Explanation

Choice A:

Withholding the next dose of the medication is not the initial action the nurse should take in response to the client's report of a rash. Lamotrigine can cause a severe skin reaction known as Stevens-Johnson syndrome, which is a medical emergency. However, discontinuing the medication abruptly without further assessment is not appropriate. The nurse should first gather more information to determine the cause of the rash.

Choice B:

Asking the client about a recent change in laundry detergent is a reasonable and responsible action. Skin rashes can be caused by various factors, including contact dermatitis from laundry detergents, soaps, or other irritants. By inquiring about potential changes in the client's environment or routines, the nurse can gather important information to help identify the cause of the rash.

Choice C:

Applying hydrocortisone cream on the client's rash without a proper assessment is not advisable. While hydrocortisone cream can help relieve itching and inflammation, it may not address the underlying cause of the rash, especially if it is due to a severe drug reaction like Stevens-Johnson syndrome.

Choice D:

Explaining that the medication causes a temporary rash is inaccurate and not recommended. While lamotrigine can cause a mild rash in some individuals, it can also lead to more serious skin reactions, as mentioned earlier. It's important to take any rash associated with lamotrigine seriously and investigate its cause before making assumptions about its temporary nature.

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Question 5:

A nurse is caring for a client who has a personality disorder and is using transference to cope.
Which of the following behaviors should the nurse expect?

A. Expressing frustration regarding unit rules. B. Reacting to the nurse as though she were his mother. C. Refusing to participate in group activities. D. Talking negatively about other staff members.

Answer and Explanation

Choice A:

Expressing frustration regarding unit rules is a possible behavior, but it doesn't directly relate to transference. It may reflect the client's general frustration or non-compliance with the rules, but it doesn't necessarily involve the transfer of feelings from a past relationship.

Choice C:

Refusing to participate in group activities can be a behavior related to a personality disorder, but it's not specifically indicative of transference. It may be more related to the client's avoidance or social difficulties.

Choice D:

Talking negatively about other staff members is another behavior that may occur in individuals with personality disorders, but it doesn't directly demonstrate transference. It could be a manifestation of their interpersonal difficulties or conflicts with staff.

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Question 6:

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

A. Auditory hallucinations. B. Flight of ideas. C. Decreased motivation. D. Impaired memory.

Answer and Explanation

Choice A:

Auditory hallucinations are considered a positive symptom of schizophrenia. Positive symptoms are characterized by the presence of abnormal experiences or behaviors that are not typically present in individuals without schizophrenia. Auditory hallucinations involve hearing voices or sounds that are not real.

Choice B:

Flight of ideas is a positive symptom of schizophrenia. It is characterized by a rapid and disorganized flow of thoughts, often leading to incoherent speech. This symptom is part of the formal thought disorder commonly seen in individuals with schizophrenia.

Choice C:

Decreased motivation is not a positive symptom; it is considered a negative symptom of schizophrenia. Negative symptoms are characterized by a reduction or loss of normal functions or behaviors that are typically present in healthy individuals. Decreased motivation reflects a lack of interest, energy, or drive to engage in activities.

Choice D:

Impaired memory is not a positive symptom but is more associated with cognitive deficits, which can be a part of schizophrenia, but it falls under cognitive symptoms rather than positive symptoms.

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Question 7:

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder.
The client states, "I feel unmotivated and don't feel like leaving my home.”. Which of the following recommendations should the nurse make to address the client's social isolation?

A. Enroll in an online self-help course. B. Practice guided imagery each morning. C. Write in a journal daily. D. Join a low-impact exercise class.

Answer and Explanation

Choice A:

Enroll in an online self-help course:While this can be beneficial for learning coping skills,it doesn't directly address the social isolation aspect.

Choice B:

Practice guided imagery each morning:This could be helpful for emotional regulation but doesn't necessarily promote socialization.

Choice C:

Write in a journal daily:Though journaling can be therapeutic,it's a solitary activity and may not address social withdrawal.

Choice D:

Join a low-impact exercise class:Participating in a group activity like a low-impact exercise class provides several benefits:
- Physical activity:Improves mood and energy levels,reducing depression symptoms.
- Social interaction:Creates opportunities to connect with others with similar interests,combating isolation.
- Structure and routine:Provides a sense of purpose and accomplishment,which can be difficult with depression.
- Reduced stress:Exercise releases endorphins,which have mood-boosting effects.

Furthermore, a low-impact class caters to the client's potential lack of motivation and energy.

Therefore, encouraging participation in a low-impact exercise class is the most suitable recommendation for this client's social isolation in the context of depression.

Remember, it's crucial to consider the client's individual preferences and tailor recommendations accordingly.

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Question 8:

A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse.
Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

A. "The client asked me to go on a date with him, but I refused.”. B. "The client needs to accept responsibility for his substance use.”. C. "The client is just like my brother who finally overcame his habit.”. D. "The client generally shares his feelings during group therapy sessions.”.

Answer and Explanation

Choice A:

"The client asked me to go on a date with him, but I refused.”. This statement does not demonstrate countertransference. It is a clear example of professional boundaries being maintained, as the staff nurse refused the client's request for a date, which is appropriate in the context of the nurse-client relationship.

Choice B:

"The client needs to accept responsibility for his substance use.”. This statement does not indicate countertransference. It reflects a common and appropriate therapeutic goal, which is to help clients take responsibility for their actions and substance use disorder.

Choice C:

"The client is just like my brother who finally overcame his habit.”. This statement represents countertransference. Countertransference occurs when a healthcare professional's emotions, attitudes, or past experiences influence their perceptions and interactions with a client. In this case, the staff nurse is making a connection between the client and their own brother, suggesting a personal bias based on past experiences. This can hinder the staff nurse's ability to provide objective care.

Choice D:

"The client generally shares his feelings during group therapy sessions.”. This statement does not demonstrate countertransference. It is a straightforward observation of the client's behavior during group therapy sessions and does not involve any emotional or personal bias on the part of the staff nurse.

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Question 9:

A nurse is developing a behavioral contract with a client who has antisocial personality disorder.
Which of the following client goals should the nurse include in the contract?

A. Use projection during group therapy. B. Decrease the number of verbal outbursts. C. Increase self-esteem. D. Use bargaining skills for behavioral consequences.

Answer and Explanation

Choice A:

Use projection during group therapy. Projection involves attributing one's own thoughts, feelings, or characteristics to another person. It is not an appropriate goal for a client with antisocial personality disorder in a therapeutic setting. Instead, the focus should be on helping the client take responsibility for their actions and develop pro-social behaviors.

Choice B:

Decrease the number of verbal outbursts. This is a suitable goal for a client with antisocial personality disorder. Clients with this disorder may exhibit impulsive and aggressive behaviors, including verbal outbursts. Decreasing such outbursts is a positive therapeutic goal that can contribute to improved interpersonal relationships and overall functioning.

Choice C:

Increase self-esteem. While improving self-esteem is important in many therapeutic settings, it may not be the primary goal for a client with antisocial personality disorder. The primary focus is often on addressing antisocial behaviors, impulsivity, and aggression, as these are the hallmark traits of this disorder.

Choice D:

Use bargaining skills for behavioral consequences. Using bargaining skills may not be the most appropriate goal for a client with antisocial personality disorder. This disorder is characterized by a persistent pattern of violating the rights of others and a disregard for social norms. Instead of bargaining, the emphasis should be on developing empathy, impulse control, and more pro-social ways of interacting with others. .

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Question 10:

A nurse is caring for a client who has depression following a recent job loss.
Which of the following questions should the nurse ask to assess the client's personal coping skills?

A. "How have you dealt with similar situations in the past?". B. "Can you describe how you are currently feeling?". C. "Do you see your current situation affecting your future?". D. "How does this situation affect your life?".

Answer and Explanation

Choice A:

The nurse should ask the client, "How have you dealt with similar situations in the past?" This question is essential to assess the client's personal coping skills. By inquiring about the client's previous experiences in handling similar situations, the nurse can gain insight into the client's coping mechanisms and identify potential strengths and weaknesses. Understanding how the client has coped in the past can help tailor interventions and support to their specific needs.

Choice B:

While asking, "Can you describe how you are currently feeling?" is a valuable question, it primarily focuses on the client's current emotional state and may not provide a comprehensive assessment of their coping skills. It is crucial to understand the client's emotions, but it does not directly address their coping strategies.

Choice C:

"Do you see your current situation affecting your future?" is a forward-looking question that explores the client's perception of how their current situation might impact their future. While this question is relevant, it does not directly assess the client's coping skills and strategies. It focuses more on the client's expectations and outlook.

Choice D:

"How does this situation affect your life?" is a broad question that can provide insights into the client's life and the impact of their current situation. However, it does not specifically address the client's coping skills and strategies. It may provide information about the consequences of their situation but not their ability to cope.

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Question 11:

A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?

A. Command hallucinations. B. Impaired memory. C. Inappropriate speech patterns. D. Rapid mood swings.

Answer and Explanation

Choice A:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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Question 12:

A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD.
Which of the following statements by the client indicates an accurate understanding of this medication's effects?

A. "I'll take my medicine at bedtime because it will make me d drowsy.”. B. "I need to tell my doctor if I start gaining weight.”. C. "This medicine will help me relax and feel less anxious.”. D. "I know that I will be able to think more clearly now.”. .

Answer and Explanation

Choice A:

"I'll take my medicine at bedtime because it will make me drowsy.”. This statement is not accurate and indicates a misunderstanding of the medication's effects. Methylphenidate, used to treat ADHD, is a stimulant medication and is not expected to cause drowsiness. Taking it at bedtime could interfere with the client's ability to sleep.

Choice B:

"I need to tell my doctor if I start gaining weight.”. While it is important to report changes in weight to the healthcare provider, this statement does not indicate an accurate understanding of the medication's effects. Weight gain is not a typical side effect of methylphenidate, and this statement does not address the medication's primary purpose.

Choice C:

"This medicine will help me relax and feel less anxious.”. This statement is incorrect as methylphenidate is not an anxiolytic medication. It is used to increase focus and reduce hyperactivity in individuals with ADHD. While some clients may experience a sense of calm as a result of improved focus, the primary purpose of the medication is not to reduce anxiety.

Choice D:

"I know that I will be able to think more clearly now.”. This statement reflects an accurate understanding of the medication's effects. Methylphenidate is a central nervous system stimulant that can help individuals with ADHD improve their focus, attention, and cognitive function. Enhanced clarity of thought is one of the intended therapeutic effects of this medication. .

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Question 13:

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night.”. Which of the following responses should the nurse make?

A. "Lots of people feel ashamed to tell their secrets.”. B. "You will feel better if you tell me what you did last night.”. C. "Let's discuss what you feel embarrassed about.”. D. "You shouldn't feel embarrassed to talk to me.”.

Answer and Explanation

Choice A:

The response, "Lots of people feel ashamed to tell their secrets," is not the most therapeutic option because it does not directly address the client's need to discuss their feelings or concerns. It does offer some empathy but falls short in terms of encouraging communication and understanding.

Choice B:

The response, "You will feel better if you tell me what you did last night," may come across as too direct and pressuring, which can be counterproductive in building trust with the client. It may make the client feel even more embarrassed or uncomfortable.

Choice D:

The response, "You shouldn't feel embarrassed to talk to me," attempts to reassure the client but may invalidate their feelings and is not as therapeutic as the correct choice. It's important to acknowledge the client's emotions and provide them with a safe space to open up.

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Question 14:

A nurse is caring for a client who is admitted to a mental health facility after attempting suicide.
Which of the following actions should the nurse take first?

A. Implement continuous one-to-one observation. B. Ask the client to sign a no-suicide contract. C. Encourage the client to participate in group therapy. D. Establish a rapport to foster trust.

Answer and Explanation

Choice A:

Implement continuous one-to-one observation:While monitoring safety is crucial,it does not address the immediate emotional need of the client,who has just endured a traumatic experience.Building trust first can facilitate open communication and help the client feel safe enough to express their feelings and needs.

Choice B:

Ask the client to sign a no-suicide contract:No-suicide contracts have limited effectiveness and can even be harmful by putting undue pressure on the client.Building trust and a collaborative plan are more effective ways to manage safety.

Choice C:

Encourage the client to participate in group therapy:Group therapy can be beneficial,but it's not appropriate as the immediate first step.Individualized attention and establishing a secure relationship are crucial at this early stage.

Choice D:

The most important action for the nurse to take first is to establish a rapport and foster trust with the client.

This will create a safe space for the client to openly express their thoughts and feelings, allowing the nurse to assess their needs and develop a proper care plan.

Remember, this is just the first step. Subsequent actions will involve a comprehensive assessment, safety measures, and collaborating with the client and other healthcare professionals to develop a personalized treatment plan.

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Question 15:

A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident.
Which of the following interventions should the nurse take first?

A. Ask staff members to describe their most traumatic memories of the event. B. Reassure staff members that the debriefing is confidential. C. Have staff members discuss their involvement in the event. D. Provide stress-management exercises to the staff members.

Answer and Explanation

Choice A:

Asking staff members to describe their most traumatic memories of the event as the first intervention may not be the best approach. This could be overwhelming and trigger emotional distress in participants. It's essential to start the debriefing with a more general and supportive approach.

Choice B:

Confidentiality is a fundamental principle in debriefing sessions, and reassuring staff members that the debriefing is confidential helps create a safe environment where they can openly discuss their experiences. This choice sets the foundation for open communication and trust among the participants.

Choice C:

Having staff members discuss their involvement in the event is important, but it's better suited for a later stage of the debriefing process. The initial focus should be on creating a safe and confidential environment for participants to express their feelings.

Choice D:

Providing stress-management exercises to the staff members is a valuable intervention but should be introduced after the initial stage of creating a safe and supportive atmosphere. It's essential to address the emotional needs and concerns of the participants before moving on to stress-management techniques. .

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Question 16:

A nurse in a provider's office is assessing a school-age child who has a spiral fracture.
The parent of the child provides different accounts of the cause of the injury.
Which of the following actions should the nurse take first?

A. Report suspected abuse to Child Protective Services. B. Determine the immediate safety needs of the child. C. Request that the parent leave the room while interviewing the child. D. Ask the child how the injury occurred.

Answer and Explanation

Choice A:

Reporting suspected abuse to Child Protective Services is important when there are concerns of child abuse. However, in this scenario, the nurse's first priority should be to ensure the immediate safety and well-being of the child. Without assessing the child's safety, it would be premature to report abuse. Child Protective Services can be involved later if necessary.

Choice C:

Requesting that the parent leave the room while interviewing the child can be a useful strategy when there are concerns about abuse or when the child needs to speak freely. However, this should not be the first action. Ensuring the child's immediate safety takes precedence.

Choice D:

Asking the child how the injury occurred is important in gathering information, but it should not be the first action. Ensuring the child's safety is of primary importance, and this information can be gathered after immediate safety needs are addressed.

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Question 17:

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam.
Which of the following laboratory results should the nurse report to the provider?

A. Hemoglobin 16 g/dL. B. WBC Count 8,000/mm3. C. RBC Count 4.9 million/mm². D. Platelets 100,000/mm3.

Answer and Explanation

Choice A:

Hemoglobin levels at 16 g/dL are within the normal range for an adult, so there is no need to report this result to the provider.

Choice B:

A white blood cell (WBC) count of 8,000/mm3 is within the normal range, and there is no need to report this result to the provider.

Choice C:

An RBC count of 4.9 million/mm² is within the normal range for adults, so it does not require reporting to the provider.

Choice D:

A platelet count of 100,000/mm3 is below the normal range (typically 150,000-450,000/mm3). This lower platelet count can increase the risk of bleeding and may be associated with clonazepam use. Therefore, it should be reported to the provider for further evaluation and potential adjustment of the medication.

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Question 18:

A charge nurse is making room assignments for new client admissions.
Which of the following clients should the nurse place closest to the nurse's station?

A. A client who has a history of dependent personality disorder. B. A client who has moderate-stage Alzheimer's disease. C. A client who has schizotypal personality disorder. D. A client who has a history of alcohol use disorder.

Answer and Explanation

Choice A:

A client with a history of dependent personality disorder does not necessarily require close placement to the nurse's station for safety reasons. The primary concern in this case is not related to Alzheimer's or potential wandering, so placing this client closer to the nurse's station is not warranted.

Choice B:

Choice B Reason: A client who has moderate-stage Alzheimer’s disease.This client should be placed closest to the nurse’s station because individuals with moderate-stage Alzheimer’s disease may experience confusion, memory loss, and wandering, which can lead to safety concerns. Close proximity to the nurse’s station allows for better supervision and prompt intervention.

Choice C:

A client with schizotypal personality disorder may have unique care needs, but these typically do not require placement close to the nurse's station. The primary concern in this case is not related to the safety or wandering associated with Alzheimer's disease.

Choice D:

A client with a history of alcohol use disorder may require monitoring and support but does not necessarily need to be placed close to the nurse's station solely based on this history. The primary concern is not related to Alzheimer's disease or safety due to wandering. In a healthcare setting, clients with Alzheimer's disease often experience confusion and may wander, creating a risk of harm to themselves. Placing a client with moderate-stage Alzheimer's disease close to the nurse's station allows for better supervision and prompt response to any safety concerns. Therefore, it is the most appropriate choice for close placement. .

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Question 19:

A nurse is reviewing the medical record of a client who is to begin taking aripiprazole.
The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

A. Hypothyroidism. B. Crohn's disease. C. Seizure disorder. D. Asthma.

Answer and Explanation

Choice A:

Hypothyroidism is not a contraindication for aripiprazole therapy. Aripiprazole is primarily used to treat conditions like schizophrenia and bipolar disorder and does not directly affect thyroid function.

Choice B:

Crohn's disease is a contraindication for aripiprazole therapy. Aripiprazole has been associated with an increased risk of gastrointestinal adverse effects, including nausea, vomiting, and constipation. In individuals with Crohn's disease, these symptoms may exacerbate the condition or lead to complications.

Choice C:

Seizure disorder is not a contraindication for aripiprazole therapy. Aripiprazole has a relatively lower risk of causing seizures compared to some other antipsychotic medications. However, caution is still advised when using aripiprazole in individuals with a seizure disorder.

Choice D:

Asthma is not a contraindication for aripiprazole therapy. Aripiprazole is not known to exacerbate asthma symptoms. It is important to monitor and manage any adverse effects in patients with asthma, but it is not a direct contraindication.

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Question 20:

A nurse is caring for a client who has schizophrenia.
The client's employer calls to discuss the client's condition.
Which of the following is the appropriate nursing action?

A. Consult the client. B. Consult the client's family. C. Contact the provider. D. Contact the facility legal department.

Answer and Explanation

Choice A:

Consulting the client is not the appropriate nursing action in this situation. Sharing the client's confidential health information with their employer without their consent would violate their privacy rights and could lead to legal and ethical issues.

Choice B:

Consulting the client's family is also not the appropriate nursing action. The client's family should not be involved in discussions about their health without the client's consent. This could breach confidentiality and privacy.

Choice C:

Contacting the provider is the appropriate nursing action. When an employer calls to discuss a client's condition, it is essential to protect the client's privacy and rights. The nurse should inform the employer that they cannot discuss the client's health information without the client's consent and should advise the employer to contact the client's healthcare provider for information regarding the client's condition.

Choice D:

Contacting the facility legal department is not the initial step to take in this situation. It is important to follow standard procedures and maintain the client's confidentiality by contacting the provider first. In cases where legal concerns arise, the legal department may become involved, but this should not be the first action.

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Question 21:

A nurse is planning to conduct a support group for adolescents who have cancer.
Which of the following actions should the nurse include during the orientation phase?

A. Maintain the group's focus on identified issues. B. Encourage the use of problem-solving skills. C. Manage conflict within the group. D. Establish a rapport with group members.

Answer and Explanation

Choice A:

Maintaining the group's focus on identified issues is a valuable aspect of group therapy, but it is not specific to the orientation phase. This action should be integrated throughout the entire support group process.

Choice B:

Encouraging the use of problem-solving skills is an important part of support group facilitation, but this is also not unique to the orientation phase. Problem-solving skills can be encouraged and developed throughout the support group sessions.

Choice C:

Managing conflict within the group is an essential skill for a support group leader, but again, this is not specific to the orientation phase. Conflict management should be an ongoing process in group therapy.

Choice D:

Establishing a rapport with group members is a critical action during the orientation phase of a support group. This phase sets the tone for the group and helps build trust and comfort among the members. It is essential for the nurse to create a safe and supportive environment where group members feel comfortable sharing their experiences and emotions. .

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Question 22:

A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline.
The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?

A. Acetaminophen. B. Warfarin. C. Fluoxetine. D. Calcium carbonate.

Answer and Explanation

Choice A:

Acetaminophen is not contraindicated when taken with selegiline. There is no significant interaction between these two medications.

Choice B:

Warfarin is not contraindicated when taken with selegiline. While selegiline may increase the risk of bleeding in combination with other drugs, warfarin itself is not directly contraindicated.

Choice C:

Fluoxetine is contraindicated when taken with selegiline. When these two drugs are used together, there is an increased risk of serotonin syndrome, which can be a life-threatening condition. Serotonin syndrome can cause symptoms such as agitation, hallucinations, rapid heartbeat, fever, muscle stiffness, and tremors.

Choice D:

Calcium carbonate is not contraindicated when taken with selegiline. These two medications do not have significant interactions.

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Question 23:

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication.
Which of the following actions should the nurse manager take first?

A. Stop the newly licensed nurse from administering the medication. B. Assess the need for physical restraints. C. Demonstrate how to verbally de-escalate the situation. D. Discuss the purpose of the medication with the client.

Answer and Explanation

Choice A:

the first step in dealing with a client who is manic and refuses treatment is to stop the nurse from administering the medication. This is because giving an injection to a patient in an agitated and manic state could be dangerous for both the patient and the nurse¹². The nurse manager should follow the principle of least restrictive intervention when handling such a situation².

Choice B:

Assessing the need for physical restraints is not a priority action, as it may escalate the situation and cause more harm than good¹².

Choice C:

Demonstrating how to verbally de-escalate the situation is also not a priority action, as it may not be effective if the client is too agitated or irrational to listen¹².

Choice D:

Discussing the purpose of the medication with the client may be helpful, but it should be done after assessing the need for physical restraints and trying other methods of communication¹².

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Question 24:

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients.
Which of the following actions is the priority for the nurse to take?

A. Role model healthy ways to express anger. B. Assist the client to explore techniques to reduce stress. C. Suggest the client make a list of things that make him angry. D. Ask the client if he intends to harm others.

Answer and Explanation

Choice A:

While role modeling healthy ways to express anger is important, it is not the priority when a client is being aggressive toward others. Safety is the primary concern.

Choice B:

Assisting the client to explore techniques to reduce stress is a helpful intervention but is not the priority when the client is actively being aggressive toward others.

Choice C:

Suggesting the client make a list of things that make him angry is a therapeutic intervention, but it is not the priority when the client's behavior poses an immediate threat to others.

Choice D:

Asking the client if he intends to harm others is the priority because it assesses the immediate risk to the safety of others. This information is crucial for determining the appropriate interventions to ensure the safety of everyone in the facility. Depending on the client's response, the nurse can take further steps to manage the aggressive behavior. Safety is the top priority in such situations. .

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Question 25:

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder.
Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

A. Significant weight loss. B. Markedly neglected hygiene. C. Poor problem-solving skills. D. Psychomotor retardation.

Answer and Explanation

Choice A:

Significant weight loss may be a concerning symptom in a client with major depressive disorder, but it is not the top priority. Major depressive disorder can lead to changes in appetite, which may result in weight loss. However, psychomotor retardation, which is a significant slowing of physical and mental activities, is a more critical finding. It can be a sign of severe depression and even potential suicidal ideation. Reporting psychomotor retardation to other disciplines allows for a prompt evaluation of the client's safety.

Choice B:

Markedly neglected hygiene is an important observation and may indicate the client's inability to perform self-care activities. While this should be addressed, psychomotor retardation takes precedence as it can indicate more severe symptoms associated with major depressive disorder.

Choice C:

Poor problem-solving skills are a common cognitive symptom of major depressive disorder, but they are not an immediate priority. Clients with depression often struggle with decision-making and problem-solving, but psychomotor retardation is a more severe and concerning symptom that warrants immediate attention.

Choice D:

Psychomotor retardation is the top priority finding in this scenario. It can be a sign of severe depression and may be associated with an increased risk of self-harm or suicide. Reporting psychomotor retardation allows the interprofessional team to assess the client's safety and initiate appropriate interventions promptly.

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