(SOLVED 2023) ATI Capstone Mental Health
a nurse working in a mental health clinic is caring for an adolescent who has a new prescription for
... [Show More] methylphenidate for the treatment of ADHD, what finding should the nurse report to the provider as AE of this medication Ans - weight loss
insomnia
dysrhythmias
a nurse in an acute care mental health facility is caring for a pt who has paranoid schizophrenia and suddenly becomes angry and uncontrollably violent toward staff. which of the following medications should the nurse expect the provider to prescribe? Ans - ziprasidone
a nurse is caring for a pt who reports a history of frequent alcohol consumption. which of the following questions should the nurse ask when screening for alcohol use disorder? Ans - has a family member indicated that you should cut down on your drinking
a nurse is caring for a pt who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdrawal. which of the following conditions should the nurse identify as causing these manifestations Ans - delirium
a nurse is reviewing the lab values of a pt who is taking lithium carbonate, what finding should the nurse expect in a pt who has a therapeutic lithium level Ans - 1.0
a nurse is assessing a pt who has delirium as a result of sepsis, which is a clinical manifestations should the nurse expect Ans - rapid mood changes
hallucinations
restlessness
a nurse is conducting a child maltreatment screening of a family who has a toddler, which of the following findings should the nurse identify as an indicator of possible child neglect Ans - the child has no immunizations since birth
a nurse is caring for a pt who exhibits excessive attention-seeking behaviors, including acting flirtatious and seductive, the nurse should suspect that the pt has what personality disorder Ans - histronic
a nurse is discussing discipline techniques with the parent of a 5 year old child, which of the following statements by the parent indicates an understanding of time out as a form of discipline Ans - I use a kitchen timer to mark the end of the time-out period
a nurse is caring for a pt who is receiving olanzapine 7.5mg PO daily, available is olanzapine 2.5mg tablets, how much should be administered Ans - 3
a nurse is assessing a pt who takes diazepam for anxiety and hydromorphone for severe pain, what is the priority finding that the nurse should report to the provider Ans - hypotension
a nurse is caring for a pt who has a new diagnosis of major depressive disorder. what medication should the nurse expect the provider to prescribe to the pt as a first-line treatment Ans - fluoxetine
a nurse is caring for a pt who has neuroleptic malignant syndrome and is experiencing hyperthermia, what medications should the nurse administer to the client Ans - acetaminophen
a nurse is planning group therapy for clients who are dealing with anxiety, which of the following actions should the nurse include in the working phase of the nurse-client relationship Ans - encourage the group to focus on improving problem solving skills
evaluate progress towards achievement of goals
a nurse is providing teaching to a pt who has a prescription for disulfiram, what statement by the pt should indicate to the nurse an understanding of the teaching Ans - if i drink alcohol, i will become very sick
a nurse is caring for a pt who has undergone ECT, the nurse should monitor the pt for which of the following AE of ECT Ans - memory deficit
a nurse is assessing an older adult client's ability to make a successful role transition to widowhood following the death of her partner, what factors should the nurse include in the assessment Ans - the client's willingness to attend a support group is correct
the client's current health status
the client's family support system
the client's involvement in a religion
a nurse is caring for a client who has depression and is taking imipramine 300mg PO divided equally every 6hr, available is imipramine 50mg tablets, how many tablets should the nurse administer per dose Ans - 1.5
a nurse is on a medical surgical unit is caring for a pt who tells the nurse that he intends to harm his ex-wife, which of the following actions is a legal duty of the nurse Ans - ensure the client's ex-wife is notified of the threat
a nurse is teaching the parent of a school-age child who has autism spectrum disorder about a new prescription for risperidone, what statement by the parent demonstrates an understanding of the teaching Ans - this med will help control my child's aggressive behavior
a nurse is caring for a client who has bipolar disorders, the client says to the nurse "give me your pen to cut the pain out of my chest" the nurse should identify that the client is at risk for which of the following Ans - self-mutilation
a nurse is caring for a client who has just learned that her partner has died by suicide, which of the following actions should the nurse take first Ans - determine the pt's understanding of the suicide events
a nurse is planning care for a pt who requires close observations, which of the following rights should the nurse identify that the pt has forfeited due to the potential for safety hazards Ans - the right to privacy
a nurse is discharging a pt who was admitted for the treatment of alcohol withdrawal, which of the following resources should the nurse recommended to the pt Ans - a 12 step program
a home health nurse is caring for an OA pt who reports feeling tired and being unable to grocery shop, what response by the nurse is an example of the therapeutic communication Ans - "let us discuss how to get you the help you need"
a nurse is providing care for a pt who is undergoing ECT, the nurse should anticipate that the pt will receive which of the following medications to reduce muscle contractions Ans - succinylcholine
a nurse is caring for a pt who has PTSD after being physically assaulted, the pt is unable to recall any details of the event, what defense mechanisms should the nurse recognize that the pt is displaying Ans - dissociation
a nurse in an acute care facility is assessing a pt who has schizophrenia, the pt states "walk tall broom short dog bell", the nurse should document the pt's speech as which of the following speech patterns Ans - word salad
a nurse is caring for an adult pt who is receiving treatment for alcohol use disorder, the client is upset because his partner told him that she does not want to visit him in the treatment facility, which of the following actions by the pt should indicate to the nurse that the pt is using regression as a defense mechanism Ans - the pt stomps his feet and throws objects off his bedside table
a nurse is preparing to teach a pt who has major depressive disorder and is scheduled to undergo ECT, which of the following statments should the nurse include in the teaching Ans - ECT is delivered thorugh electrodes attached to the head
a nurse is caring for a pt who is experiencing seizures related to alcohol withdrawal, which medication should the nurse plan to administer Ans - chlordiazepoxide
a nurse is admitting a pt who has PTSD to a community mental health facility. what manifestations should the nurse expect when completing the admission assessment Ans - reluctance to discuss the event that precipitated the distress
a charge nurse working in a mental health unit is concerned that a nurse who is caring for a pt is experiencing countertransferance, which of the following behaviors should the charge nurse identify as an indication of countertransference Ans - the nurse is inattentive when spending time with the pt
a nurse is caring for a pt who has a history of suicided attempts, which of the following findings places the client at risk for another suicide attempt Ans - hallucinations
depression
delusions
a nurse is caring for a pt who is agitated and tells the nurse "my life is not worth living" which of the following actions should the nurse take first Ans - ask the client if she has plan for self-injury
a nurse is reviewing the medical records of a group of pts, for what should the nurse recommend a referral for assertive community treatment Ans - a client who has repeated acute care admissions due to schizophrenia
a nurse is conducting an admission assessment for a pt who is experiencing a manic episode of bipolar disorder, what behaviors should the nurse expect Ans - grandiosity
flight of ideas
hyperactivity
a nurse is caring for a pt who is taking clozapine for the treatment of schizophrenia and reports hypersalivation, what classifications of medication should the nurse expect to be prescribed to alleviate this adverse effect Ans - anticholinergic
a nurse is planning care for a pt who attempted suicide, what following interventions is the priority for the nurse to include in the plan Ans - initiate constant one-to-one observation
a nurse is providing care for a pt who is being discharged with prescription for phenelzine to treat depression, the nurse should instruct the pt to avoid which of the following foods Ans - bologna
a nurse is administering an antidepressant medication to a pt, the nurse should understand which of the following is the major difference between SRRIs and TCAs Ans - TCAs are lethal in overdose
a nurse is planning to teach a pt who is taking lithium, what should the nurse include in the teaching as possible adverse effects of therapeutic lithium levels Ans - weight gain and dry mouth
a nurse is caring for a pt who is taking tricyclic antidepressant, for which of the following findings should the nurse monitor as an adverse effect of tricyclic antidepressants Ans - orthostatic hypotension
a nurse is reviewing the health history of an adolescent pt who has anorexia nervosa, the nurse should identify that a pt who has anorexia nervosa is also likely to have which of the following comorbidities? Ans - anxiety disorder
oppositional defiant disorder
major depressive disorder
borderline personality disorder
a nurse is caring for a 4year old child who has ASD, which behavior would the nurse expect Ans - lack of eye contact
constant spinning of a toy
temper tantrum
a mental health nurse is providing preventative care for a group of pts in the community, what actions by the nurse demonstrates a secondary prevention strategy Ans - screening college students who demonstrate manifestations of schizophrenia
a nurse in a community health facility is assessing a pt who is experiencing rape-trauma syndrome, what finding should the nurse expect Ans - report of violet dreams
a nurse is providing teaching to a pt who has insomnia and has recently begun taking zolpidem, what AE should the nurse instruct the pt to monitor Ans - sleep driving
dizziness
daytime drowsiness
a nurse is admitting a pt who has BPD and is at risk for self-mutilation, what interventions should the nurse incorporate in the plan of care Ans - obtain a verbal contract from the pt
a nurse is caring for a pt who is OCD, what manifestations of OCD should the nurse expect Ans - rigid adherence to daily routine
perfectionism
reluctance to delegate tasks
a nurse is discussing the use of mechanical restraints with a newly licensed nurse, what situations should the nurse include as an indication for placing a pt in mechanical restraints Ans - self-destructive behavior despite alternative interventions
a charge nurse is teaching a group of nurses about the antagonist action of medications, the nurse should include in the teaching that which of the following antagonist medications is used for benzodiazepines Ans - flumazenil
a nurse is assessing a pt who has PTSD following a sexual assault, what is an expected finding Ans - increasing feelings of anger
a nurse is conducting a group therapy session for several clients, the group is laughing at a joke one of the pts told,when a pt who is schizophrenic jumps up and runs out of the room yelling, "you are all making fun of me" the nurse should identify this behavior as which of the following characteristics of schizophrenia Ans - ideas of reference
a nurse is caring for a pt who has a mental illness, which of the following actions by the nurse demonstrates the ethical concept of autonomy Ans - supporting the pt wish to refuse prescribed medications
a nurse is assessing a pt who has illness anxiety disorder, which of the following findings should the nurse expect Ans - constant worry about the undiagnosed presence of an illness
a nurse is caring for a pt who was admitted with acute psychosis and is being treated with haloperidol, the nurse should suspect that the pt may be experiencing TD when the pt exhibits Ans - tongue thrusting and lip smacking
facial grimacing and eye blinking
involuntary pelvic rocking and hip thrusting movements
a nurse is developing a care plan for a pt who has schizophrenia and is taking chlorpromazine, which of the following actions should the nurse include in the plan Ans - monitor the pts respirations every 4hours
a nurse is caring for a pt who has bipolar disorder, the pt states "i feel like superman, i can do anything, i can fly home today and then become a US senator" which of the following findings is this pt exhibiting Ans - grandiosity
a nurse is reviewing abnormal laboratory values for four pts who have schizophrenia and take clozapine, which client should the nurse withhold the meds and notify the provider immediately to have clozapine therapy discontinued Ans - a pt who has a WBC of 2,900
a nurse is teaching a male pt who has a depressive disorder about sertraline, which of the following information should the nurse include in the teaching Ans - this medication may cause an inability to orgasm
a nurse overhears a pt who has schizophrenia talking to herself, the pt keeps stating "the flakalas are here, the flakalas are here" the nurse correctly recognizes the pts use of the word flakala as an example of which of the following alterations ins speech Ans - neologism
a nurse is caring for a pt who is in denial over losing a limb in a motor vehicle crash two weeks ago, which of the following actions should the nurse take Ans - slowly intervene to help the pt develop awareness of the loss of his limbs
a nurse is caring for a pt who is undergoing ECT for the treatment of depression, what actions should the nurse take prior to scheduled ECT Ans - request an ECG
witness the informed consent
check the pt's BP
a nurse is developing a plan of care for a newly admitted pt who has schizophrenia and experiences frequent hallucinations and paranoid delusions, which of the following actions should the nurse plan to take Ans - limit the number of questions asked during assessments
a home health nurse is speaking to a group of acute care nurses about domestic violence, which of the following statements by one of the acute care nurses indicates a need for clarification Ans - i have heard that abusers think of themselves as important and have high self esteem
a nurse is caring for a group of older adult pts, what of the following manifestations indicates one of the clients is experiencing delirium Ans - a pt attempts to climb out of bed and repeatedly states she must get home
a nurse is caring for a 9year old who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. the mother tells the nurse she is afraid to let him take part in physical activities at school, which of the following responses should the nurse make Ans - "tell me more about how you are feeling about your son's activities"
a nurse is teaching a newly-admitted pt about the possible physical effects of alcohol withdrawal, which of the following manifestations should the nurse include in the teachings Ans - seizures
illusions
tremors
a nurse is caring for a pt who requires a crisis intervention for acute anxiety, which of the following actions is the highest priority Ans - protecting the pt from injury
during a group therapy session, a nurse notes several pts using multiple defense mechanisms, which of the following pt statements demonstrates the maladaptive use of regression Ans - "i dont care about work anymore since I was not given a promotion"
a nurse is admitting a pt to an alcohol abuse program, the pt states "i am here because of my boss, it was part of my job to go to parties and drink with clients" the pt statement is an example of which of the following defense mechanism Ans - rationalization
a nurse is caring for a pt following a suicide attempt, the pt has a history of depression, substance abuse, and anorexia nervosa, which of the following actions in the nurse's priority Ans - initiating suicide precautions
a nurse on an inpatient eating disorders unit is caring for a pt who has anorexia nervosa and has a body mass index of 17.2, which of the following actions should the nurse take Ans - provide the pt with small meals frequently
monitor the pt's weight daily
stay with the pt during meals and for 1 hour afterwards
offer specific priviliges for sustained weight gain [Show Less]