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ATI Book Mental Health Chapters 12, 13, 14, 21, 22
Terms in this set (25)
A nurse working on an acute mental health unit is caring for a client who has post traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (SATA)
A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes
A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (SATA)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
E. Take advantage of offered counseling
A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?
A. The client remembers many details about the traumatic incident
B. The client expresses heightened elation about what is happening
C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred
D. The client expresses a sense of unreality about the traumatic incident
A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?
A. The client explains that her body seems to be floating above the ground
B. The client has the idea that someone is trying to kill her and steal her money
C. The client states that the furniture in the room seems to be small and far away
D. The client cannot recall anything that happened during the past 2 weeks
A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?
A. Teach the client to recognize how stress brings on a personality change in the client
B. Repeatedly present the client with information about past events
C. Make decisions for the client regarding routine daily activities
D. Work with the client on grounding techniques
A nurse working in an acute mental health facility is caring for a 35‑year‑old female client who has manifestations of depression. The client lives at home with her partner and two young children. she currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (SATA)
C. History of chronic asthma
E. Being married
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority?
A. Placing the client on one‑to‑one observation
B. Assisting the client to perform ADLs
C. Encouraging the client to participate in counseling
D. Teaching the client about medication adverse effects
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?
A. "I can expect my problems with PMDD to be worst when I'm menstruating."
B. "I will use light therapy 30 minutes a day to prevent further recurrences of PMDD."
C. "I am aware that my PMDD causes me to have rapid mood swings."
D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."
A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "Care during the continuation phase focuses on treating continued manifestations of MDD."
B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks."
C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."
D. "Medication and psychotherapy are most effective during the acute phase of MDD."
A nurse is interviewing a 25‑year‑old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect?
A. Wide fluctuations in mood
B. Report of a minimum of five clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self‑esteem
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (SATA)
A. Provide flexible client behavior expectations
B. Offer concise explanations
C. Establish consistent limits
D. Disregard client complaints
E. Use a firm approach with communication
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?
A. "ECT is the recommended initial treatment for bipolar disorder."
B. "ECT is contraindicated for clients who have suicidal ideation."
C. "ECT is effective for clients who are experiencing severe mania."
D. "ECT is prescribed to prevent relapse of bipolar disorder."
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?
A. Set consistent limits for expected client behavior
B. Administer prescribed medications as scheduled
C. Provide the client with step-by-step instructions during hygiene activities
D. Monitor the client for escalating behavior
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make?
A. "Why do you think you feel the need to give money away?"
B. "I am here to provide care and cannot accept this from you."
C. "I can request that your case manager discuss appropriate charity options with you."
D. "You should know that giving away your money is inappropriate."
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (SATA)
A. Use caffeine in moderation to prevent relapse.
B. Difficulty sleeping can indicate a relapse.
C. Begin taking your medications as soon as a relapse begins.
D. Participating in psychotherapy can help prevent a relapse.
E. Anhedonia is a clinical manifestation of a depressive relapse.
A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit.
B. Combining alcohol with diazepam will produce a paradoxical response.
C. Diazepam has a lower risk for dependence than other anti-anxiety medications.
D. Report confusion as a potential indication of toxicity.
A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority?
A. Administer flumazenil
B. Identify the client's level of orientation
C. Infuse IV fluids
D. Prepare the client for gastric lavage
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication?
A. "I will take the medication at bedtime."
B. "I will follow a low‑sodium diet while taking this medication."
C. "I will need to discontinue this medication slowly."
D. "I will be at risk for weight loss with long‑term use of this medication."
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (SATA)
C. Muscular flaccidity
A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (SATA)
A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard
D. Changing to a different class of anti-anxiety medication
E. Increasing the dose of paroxetine
A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash."
B. "I may feel drowsy for a few weeks after starting this medication."
C. "I cannot eat my favorite pizza with pepperoni while taking this medication."
D. "This medication will help me lose the weight that I have gained over the last year."
A nurse is caring for a client who is taking phenelzine for which of the following adverse effects should the nurse monitor? (SATA)
A. Elevated blood glucose level
B. Orthostatic hypotension
A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?
A. The client has a family history of seasonal pattern depression.
B. The client currently smokes 1.5 packs of cigarettes per day.
C. The client had a motor vehicle crash last year and sustained a head injury.
D. The client has a BMI of 25 and has gained 10 lb. over the last year.
A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (SATA)
A. Void just before taking the medication.
B. Increase the dietary intake of potassium.
C. Wear sunglasses when outside.
D. Change positions slowly when getting up.
E. Chew sugarless gum.
A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?
A. "This medication increases the release of serotonin and norepinephrine."
B. "I will need to monitor the client for hyponatremia while taking this medication."
C. "This medication is contraindicated for clients who have an eating disorder."
D. "Sexual dysfunction is a common adverse effect of this medication."
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