VATI Mental Health Exam - Questions, Answers and Rationales A nurse is providing dietary teaching to a client who has a prescription for tranylcypromine.
... [Show More] The nurse should instruct the client to avoid which of the following foods while taking this medication? -Cream cheese -Grapefruit -Avocados -Fresh Salmon -High tyramine content, which promotes the release of norepinephrine from sympathetic neurons. Consuming avocados while taking tranylcypromine can result in a hypertensive crisis due to massive vasoconstriction and excessive stimulation of the heart. Tyramine levels are highest in very ripe avocados. Aged cheeses are contraindicated for clients taking MAOIs; Most fruits, except for overripe figs and bananas, are safe for clients taking MAOIs; Smoked salmon and other dried, cured, smoked, aged, or fermented fish are unsafe for clients taking MAOIs A nurse is planning care for a client who is taking benztropine to reduce extrapyramidal manifestations developed secondary to taking an antipsychotic medication. For which of the following adverse effects of benztropine should the nurse monitor? Diaphoresis Tachycardia Diarrhea Polyuria -At risk for palpitations and tachycardia caused by anticholinergic toxicity. Common adverse effects associated with anticholinergic medications include dry mouth, blurred vision, urinary retention, constipation, photophobia, and tachycardia. Benztropine is commonly prescribed for clients who take antipsychotic agents and who are experiencing extrapyramidal effects, such as Pseudoparkinsonism with tremors, shuffling gait, and drooling or dystonia with painful contractions of the jaw or neck. *decreased sweating (diaphoresis_ *increase risk for constipation *risk for urinary retention A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect? Avoids self responsibility. -Has a great need to be taken care of, which leads to fears of separation, difficulty making decisions, and avoidance of taking responsibility for most aspects of life. A nurse is planning care for a client who is withdrawing from alcohol. Which of the following medications should the nurse plan to administer during the acute phase of alcohol withdrawal? - Varenicline - Diazepam - Disulfiram - Acamprosate -Benzodiazepine, to client during acute alcohol withdrawal to raise the seizure threshold and prevent seizures, decrease agitation, stabilized vital signs, decrease the intensity of withdrawal manifestations, and prevent delirium tremens. A charge nurse is conducting an in-service for a group of newly licensed nurses about risk factors for child maltreatment. Which of the following examples should the nurse include in the teaching? A child who has acute bronchiolitis A child who was born with a cleft lip and palate A parent who grew up as part of an extended family A parent who has high self-esteem -Having a congenital abnormality, such as cleft lip and palate, increases a child's risk for bring maltreated. The nurse should also teach the group of nurses that children who are younger than 3 years of age and children from an unwanted pregnancy are at risk for maltreatment. A nurse in an acute care mental health facility is caring for a client who has generalized anxiety disorder and suddenly begins pacing, wringing her hands, and reporting numbness and tingling in her fingers. Which of the following actions should the nurse take? Walk with the client while setting physical limits on her behavior. - The client is experiencing panic level anxiety and might display unsafe behavior during this time. The nurse should stay with the client and allow her to walk around to decrease tension and anxiety. A nurse is caring for a client who has schizophrenia and is exhibiting violent behavior. After staff members place the client in restraints, which of the following actions should the nurse take? -Document the client's behavior hourly. -Release the restraints when the client goes to sleep. -Offer toileting to the client every 4 hr. -Request that the provider see the client within 1 hr. -Notify the clients provider of the need for restraints and request that the provider assess the client within 1hr. behavior should be checked (15min), restraints removed once behavior is controlled, toileting offered q1-2h A nurse in a mental health facility is caring for a client who has frequent episodes of aggressive and violent behavior. The nurse should identify which of the following findings as indications that the client is at risk for imminent violence? SATA Uses profanity to express emotions. Clenches and unclenches the jaw. Maintains intense eye contact. Paces the floor. -Increase in profanity can be a manifestation of escalating behavior, which can signal a violent episode. Some clients speak more loudly when they become angry, while others become very quiet or speak more softly. -As behavior escalates toward violence, the nurse might observe the client clenching and unclenching the jaw or fist, or standing with a rigid posture. -Maintaining intense eye contact or suddenly avoiding eye contact are manifestations associated with imminent violence. -Client who becomes more active or restless and paces often around the unit is at a high risk for becoming violent. A nurse is assigning tasks to a licensed practical nurse and an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? -Witness a client's signature on an informed consent for electroconvulsive therapy -Remain with a client who has anorexia nervosa following a meal. -Determine the risk for suicide of a client who has attempted self-injury. -Complete the CAGE questionnaire with a client who has been admitted for observation. -At risk for purging following a meal. It is within the range of function of the AP to remain with the client following the meal to ensure the client complies with the plan of care and does not purge. A nurse is preparing to administer methylphenidate 30mg PO to a school age child who has ADHD. Available is methylphenidate oral solution 10mg/5mL. How many mL should the nurse administer? 15 Ml [Show Less]