2023 ATI RN Mental Health Online Practice B A nurse is teaching a client who has depressive disorder about fluoxetine. Which of the following
... [Show More] information should the nurse include in the teaching? 1. "You might notice an increase in saliva while taking this medication." 2. "You might experience difficulties with sexual functioning while taking this medication." 3. "You should expect an improvement in symptoms of depression in 3 to 4 days." 4. "You may notice a temporary ringing in the ears when starting this medication." - 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. A nurse is reviewing the medical record or a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication that the client require hospitalization? 1. Total body fat 8.7% 2. Potassium 3.6 mEq/L (3.5 to 5 mEq/L) 3. Temperature 36.1° C (96.9° F) 4. Heart rate 54/min - 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. 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? 1. "They work so hard at ballet. Will they still be able to perform?" 2. "They're happier with their appearance now that they've lost some weight." 3. "They told me they were tired, so I did their chores for them today." 4. "They won't let me take the trash from their room. I'm concerned about what they have in there." - 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. 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?
1. Decrease distractions during meal times. 2. Provide positive feedback when the child completes a task. 3. Clearly identify consequences for unacceptable behavior. 4. Remove unnecessary equipment from the child's surroundings. - 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. A nurse obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? 1. Raise the pitch of the voice when speaking to the client. 2. Begin the interview by explaining the plan of care. 3. Interview the client in a private setting. 4. Ask the client to complete a detailed questionnaire. - 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 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? 1. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. 2. The client reports an inability to breathe easily. 3. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL (74 to 106 mg/dL) 4. The client reports having recently started smoking cigarettes. - 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. 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? 1. Blurred vision 2. Orthostatic hypotension 3. Dry mouth 4. Acute dystonia - The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine. 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? 1. "I am going to order a wheelchair for when I'm unable to walk." 2. "I am going to stop paying my bills since I won't be around much longer." 3. "I wish you would go take care of somebody who actually needs you." 4. "I am sure I'll be able to continue to care for myself without help." - 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. 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? 1. Obtain the weight of a client who has bipolar disorder and is experiencing mania. 2. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. 3. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. 4. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. - 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 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? [Show Less]