A nurse is caring for a client who has bipolar disorder and a new prescription for lithium

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

A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching

"Take this medication with food R: Lithium can cause GI distress

A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs

A client who has severe Alzheimer's disease R: these pt are typically confused, have memory difficulties, tend to wander, and will need assistance

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

Identify the client's trigger foods R: to help pt understand the thoughts and behaviors that relate to the food

A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse

A family where one or both parents witnessed intimate partner violence in the home as children R: They are more likely to become abused themselves.

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first

Inform the client that her admission is confidential

A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent

A 35-year-old client who has major depressive disorder R: pt w majar depressive d/o can make decisions unless legally incompetent

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his 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 R: clang often rhymes or contains a string of words tha can have the same beginning sounds

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching

Language delay R: typical manifestation

A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take?

Ask the client what the voices are saying R: to determine if the pt or others are at risk for injury

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make

"Let's talk about what is upsetting you." R: nurse is acknowledging the ot concerns and is showing desire to understand what the pt is thinking and feeling

A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first

Discuss the importance of hair with the client R: 1st action for a nurse is to assess the pt, the experience of anticipatory grieving begins w the importance of the expected loss

A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data

Sodium level 125 mEq/l R: In the presence of low Na+ levels, renal excretion of Li is reduced and the pt is at risk for Li toxicity

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD)

Lack of interest in an upcoming holiday R: pt w PTSD will have - moods, child can also have loss or lack of interest and participation in significant activities.

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take

Gather supplies for endotracheal intubation R: the expected finding is resp depression

A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first

A client who is experiencing delusions of persecution R: greatest risk due to the pt belief that a person in power is out to harm him.

A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation

Nonmaleficence R: it is the responsibility of the nurse to not harm the pt.

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

A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include

Attending a relapse prevention group several times each week R: most effective relapse prevention is a 12 step program such as AA

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

Attention to body language R: active listening involves identifying verbal and nonverbal communication

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse

"Succinylcholine is given to reduce muscle movements during therapy R: succinylocholine is a muscle paralyzing agent that will decrease muscle movement during the procedure so that injury is less likely to occur

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

Giving away possession R: giving away possessions indicates that the pt is a greater risk for suicide.

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior

"If you do my homework for me, I won't bother you for the rest of the day R: this is an ex of manipulative behavior

A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement

Discuss spiritual issues in a conversational manner

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

Provide frequent high-calorie snacks R: Maslow's requirement is for adequate nutrition

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include

Early identification of changes, such as decreased social involvement, is important R: decreased social involvement in a manifestation of depression, and early identification of findings can lead to early intervention

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment

Orthostatic hypotension R: low wt, electrolyte imbalance, starvation, and dehydration can cause this

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider

Inability to sleep R: pt is extremely active and doesn't sleep, which can lead to relapse.

A charge nurse is developing an educational program about schizophrenia. Which of the following manifestations should the nurse include as a negative symptom of schizophrenia

Thought blocking R: thought block is a - symptom of schizo. It is a sudden interruption in pt thought processes usually due to internal stimuli

A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching

"Administer the last dose of medication to your child 6 hours before bedtime R: A/E of dextro. is insomnia

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take

Ask the family member if she has any thoughts or questions about the treatment plan

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

A nurse in a provider's office is collecting a health history from the parent of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the parent is the priority for the nurse to report to the provider

Dark urine R: greatest risk for a child is liver damage from atomoxetine, which can progress to failure and death.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists in orienting the client to reality

Talk with the client about scheduled daily activities R: this can orient the pt to time and reality throughout the day

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

Rhinorrhea R: rhinorrhea and flu like manifestions such as yawning, sneezing, and abd pain

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan

Identify signs of escalation of violence

A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? (Select all that apply

- Pt who is suicidal and need rapid tx R: ECT is a rapid, definitive response for suicidal pt -pt w bipolar d/o w rapid cycling R: works best for these pt -pt w mania and not responding to med therapy

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take

Do not administer the lorazepam R: pt who is involuntarily admitted have the right to refuse tx

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 refrain from self-mutilation R: greatest risk is injury to self or others

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

"I will talk about my feelings with a close friend." R: discussion feelings w a support person is effective coping

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief

"I feel so empty without my wife that it's hard to get up every morning." R: difficulty carrying on w normal activities indicates a risk for complicated grief

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care

Permit the client to perform daily rituals to decrease anxiety R: allowing them to do so will decrease frustration and anxiety

A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness

"I am going to order a wheelchair for when I'm unable to walk." R: pt is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, indicative of acceptance.

A nurse in the emergency department is admitting a client who reports a headache along with heart palpitations after having a glass of wine with dinner a few hours ago. The client has a history of depression and has a blood pressure of 210/105 mm Hg. Which of the following questions should the nurse ask first

"What medications are you currently taking?" R: If the pt is taking MAOI to tx depression, they are at a greater risk for hypertensive crisis, it can also be precipitated by tyramine containing food

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 not take charge of my partner's work responsibilities

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 R: unexpected events

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

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client

Set realistic limits on the client's behavior R: these pt can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive.

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

Talk with the client about activities she enjoyed with her partner R: talking about + experiences can help distract her from disorientation

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect

Hypertension R: it is a stimulant that increase BP, HR, body temp, energy levels, and metabolism

During a client's initial interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors

The client is interested in what the nurse is saying

A charge nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following information should the nurse include in the teaching

The right to treatment ensures individualized care R: The Hospitalization of the Mentally Ill Act of 1964 requires that pt admitted to an inpatient mental health facility have a right to individualized tx

A nurse is teaching the parents of a client about their daughter's diagnosis of bulimia nervosa. Which of the following statements made by the parents indicates an understanding of their daughter's illness

"It is important for our daughter to have regular dental checkups R: repeated vomiting erodes tooth enamel and predisposes the teeth to caries.

A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication

Urinary retention R: OD can result in anticholinergic effects and the pt is more likely to experience constipation rather than loose stools

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) R: it is an enzyme released when muscle tissue is damaged

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 may experience difficulties with sexual functioning while taking this medication R: SSRI can cause sexual dysfunction

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

An older adult client who is bedbound and has a stage IV pressure ulcer R: Stage 4 pressure ulcer in a pt who is bedbound can indicate physical neglect and warrants reporting

A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate

A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication

The client reports a sore throat R: clozapine can lead to a fatal blood d/o, agranulocytosis. this is a severe drop in WBC which leaves them at risk for infection. Nurse should w/hold

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero

What are the 3 main symptoms of lithium toxicity?

Which of the following instructions should you give to a patient taking lithium carbonate?

What are normal lithium levels?

What mental illness does lithium treat?