Ati rn mental health 2023 with NGN
Total Questions : 52
Showing 25 questions, Sign in for moreA nurse is developing a care plan for a client with schizophrenia who is experiencing command hallucinations. Which of the following interventions should be included in the plan?
Explanation
Choice A reason: Providing reassurance and comfort through touch can be beneficial in some cases; however, for clients experiencing command hallucinations, physical touch may be misinterpreted and could potentially escalate the situation. It's essential to gauge the client's comfort level with touch and proceed cautiously.
Choice B reason: While socialization is an important aspect of recovery, for a client experiencing command hallucinations, group therapy might be overwhelming and could exacerbate the hallucinations. It's crucial to introduce socialization gradually and in a controlled environment.
Choice C reason: Eye contact can be perceived as threatening or confrontational by clients with schizophrenia, especially when experiencing command hallucinations. It's important to respect the client's space and use non-confrontational body language to communicate effectively.
Choice D reason: Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. A calm and quiet environment can help reduce the intensity and frequency of hallucinations, providing a sense of safety and reducing stress and anxiety.
A nurse is looking after a client with obsessive-compulsive personality disorder (OCPD). What findings should the nurse anticipate?
Explanation
Choice A reason: Lack of empathy is not a characteristic finding in OCPD. While individuals with OCPD may appear insensitive or less responsive to the needs and feelings of others due to their focus on rules and productivity, this does not equate to a true lack of empathy.
Choice B reason: Preoccupation with details is a hallmark of OCPD. Individuals with this disorder have an excessive concern with orderliness, perfectionism, and control over their environment and tasks. They may become so involved in making every detail perfect that it can hinder task completion and efficiency.
Choice C reason: Exploitative behavior is more characteristic of other personality disorders, such as narcissistic personality disorder, and is not a typical feature of OCPD. People with OCPD are more likely to be overly conscientious and fair in their dealings with others.
Choice D reason: Excessive clinging is not typically associated with OCPD. Instead, individuals with OCPD may have difficulty delegating tasks or working with others unless things are done precisely their way, which stems from their need for control rather than a need for closeness or reassurance.
A nurse is attending to a client who is navigating the grieving process. What actions should the nurse take to address the client’s spiritual needs?
Explanation
Choice A reason: Encouraging the client to internalize their feelings related to the loss is not advisable. Grief is a personal experience, and expressing emotions is a healthy part of the grieving process. Internalizing feelings can lead to unresolved grief and potential mental health issues.
Choice B reason: Changing the subject when the client expresses anger about their situation is not supportive. Anger is a natural stage of the grieving process, and it's important for the nurse to acknowledge the client's feelings and provide a safe space for them to express their emotions.
Choice C reason: Allowing the client to be alone during times of spiritual inadequacy may not be beneficial. While respecting the client's need for solitude is important, it's also crucial to offer support and presence, as isolation can exacerbate feelings of loneliness and despair.
Choice D reason: Offering to contact the client's spiritual advisor is a supportive action that can help meet the client's spiritual needs. Spiritual care is an integral part of holistic nursing care, and connecting the client with their spiritual support system can provide comfort and aid in the grievin
A nurse is assisting a client who wants to quit smoking. What prescription should the nurse anticipate the provider will recommend?
Explanation
Choice A reason: Naltrexone is primarily used to manage alcohol or opioid dependence and is not typically prescribed for smoking cessation. It works by blocking the euphoric effects of these substances, which is not directly applicable to nicotine addiction.
Choice B reason: Disulfiram is used as a deterrent agent in the treatment of alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed, thus it is not suitable for smoking cessation.
Choice C reason: Varenicline is a medication specifically designed to aid in smoking cessation. It works by binding to nicotine receptors in the brain, reducing cravings and the pleasurable effects of smoking. This makes it easier for individuals to quit smoking.
Choice D reason: Donepezil is a medication used to treat cognitive symptoms of Alzheimer's disease. It is not indicated for smoking cessation and does not have an effect on nicotine addiction.
A nurse in an acute care mental health facility is attending to a client who has been placed in seclusion after a severe violent incident. What actions should the nurse take?
Explanation
Choice A reason: Keeping the client in seclusion for no longer than 6 hours is not a standard practice. The duration of seclusion should be based on the client's condition and behavior, with continuous assessment to determine the need for ongoing seclusion.
Choice B reason: Obtaining a prescription for seclusion within 30 minutes is essential to ensure that the seclusion is legally authorized and that the client's rights are protected. However, the priority is to address the immediate safety concerns and then secure the prescription as soon as possible.
Choice C reason: Monitoring the client's vital signs every 4 hours is important, but it may not be sufficient in a seclusion scenario. The client's condition can change rapidly, and more frequent monitoring may be necessary to ensure their safety.
Choice D reason: Documenting the client's behavior every 60 minutes is a critical action. Regular documentation helps in assessing the client's progress, provides a record for legal and ethical accountability, and informs decisions about continuing or ending seclusion.
A nurse is looking after a client who says, "I am too embarrassed to tell anyone what I did last night." What response should the nurse give?
Explanation
Choice A reason: This response may seem dismissive and could minimize the client's feelings. It's important to acknowledge the client's emotions as valid and unique to their experience, rather than comparing them to others.
Choice B reason: This response invites the client to share their feelings in a non-judgmental space and shows the nurse's willingness to listen. It respects the client's autonomy and provides an opportunity for them to open up about their concerns at their own pace.
Choice C reason: While this response is meant to be reassuring, it may inadvertently invalidate the client's feelings. Embarrassment is a personal emotion, and what might seem trivial to one person can be significant to another.
Choice D reason: This response implies that sharing will lead to relief, which may not always be the case. It also puts pressure on the client to disclose information before they are ready, which could be counterproductive.
A nurse in a rehabilitation center is treating a client with bipolar disorder. Which of the following behaviors by the client indicates mania?
Explanation
Choice A reason: Constant talking is a common indicator of mania in individuals with bipolar disorder. During manic episodes, clients may experience pressured speech, which is fast, incessant, and difficult to interrupt. This symptom reflects the increased energy and reduced need for sleep that are characteristic of mania.
Choice B reason: While memory loss is not a definitive indicator of mania, it can occur in bipolar disorder. However, it is more commonly associated with either depressive episodes or the aftermath of a manic episode, rather than the manic phase itself.
Choice C reason: Excessive sleep is typically not associated with mania. In fact, a decreased need for sleep is one of the diagnostic criteria for a manic episode. Clients in a manic phase often feel rested after only a few hours of sleep.
Choice D reason: Expressing feelings of inferiority is not typically indicative of mania. Such feelings are more commonly associated with depressive episodes. Manic episodes often involve inflated self-esteem or grandiosity.
A nurse is getting ready to educate a client with moderate anxiety about what to expect following their upcoming cardiac catheterization. What actions should the nurse plan to take?
Explanation
Choice A reason: Providing detailed explanations to a client with moderate anxiety might overwhelm them and exacerbate their anxiety. While information is important, too much detail can be counterproductive in this context.
Choice B reason: Using short, simple sentences can help ensure that the client with moderate anxiety comprehends the information without becoming overwhelmed. This approach is conducive to learning and retention, especially when the client is anxious.
Choice C reason: Avoiding asking the client questions may seem like a way to reduce stress, but it can actually hinder engagement and understanding. Questions can help clarify the client's comprehension and provide them with a sense of involvement in their care.
Choice D reason: Showing a 30-minute teaching video might be informative, but it could be too lengthy for a client with moderate anxiety. The client may benefit more from interactive and personalized teaching methods that allow for breaks and questions as needed.
A nurse is attending to a client with major depressive disorder who mentions that they have given away their personal belongings. What response should the nurse provide?
Explanation
Choice A reason: Asking "Why did you feel like giving away your belongings?" could be perceived as confrontational or judgmental. It's important to approach the client with empathy and without implying that their actions were wrong or require justification.
Choice B reason: "Can you tell me how you have been feeling lately?" is an open-ended question that invites the client to share their feelings and experiences. It demonstrates the nurse's interest in understanding the client's emotional state and provides a safe space for the client to express themselves.
Choice C reason: Saying "Everyone feels a little down sometimes." minimizes the client's experience and the severity of major depressive disorder. It fails to acknowledge the unique and serious nature of the client's condition.
Choice D reason: While suggesting "You should find a support group to attend." can be helpful, it may be more appropriate after establishing a rapport and understanding the client's current state. It's also important to offer support in finding resources rather than directing the client.
A nurse is gathering a history from a client who has been using olanzapine to treat schizophrenia. What question should the nurse ask the client?
Explanation
Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.
Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.
Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.
Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.
A nurse is looking after a client with a depressive disorder. The client says, "I don't always go to bed at night, so I get in trouble for falling asleep at work." What intervention should the nurse suggest?
Explanation
Choice A reason: Taking a 1-hour nap every day is not recommended for individuals with sleep disruptions, especially due to depressive disorder, as it can further disrupt nighttime sleep patterns.
Choice B reason: Exercising late in the day can be stimulating and may make it harder to fall asleep. It is generally advised to exercise earlier in the day to improve sleep quality.
Choice C reason: Keeping a sleep diary is a beneficial intervention for individuals with sleep disruptions. It can help identify patterns and behaviors that affect sleep and is a step towards establishing a consistent sleep schedule.
Choice D reason: Discontinuing medication without medical advice is not safe. Medications for depressive disorder should be managed by a healthcare provider, especially as abrupt changes can have serious consequences.
A nurse is attending to a client with borderline personality disorder. What outcomes should the nurse incorporate into the treatment plan?
Explanation
Choice A reason: While verbalizing an improved mood is a positive outcome, it is not specific to borderline personality disorder and does not directly address the behavioral aspects of the condition.
Choice B reason: Hallucinations are not a typical symptom of borderline personality disorder; they are more commonly associated with psychotic disorders. Therefore, a decrease in hallucinations would not be a relevant treatment outcome for this condition.
Choice C reason: Attending to personal hygiene can be a significant issue for clients with borderline personality disorder, as self-care routines may be neglected during periods of intense emotional distress. Including this in the treatment plan focuses on improving daily functioning and self-care abilities.
Choice D reason: Communicating needs is an important skill for all clients, but it is not specific to the treatment of borderline personality disorder. The focus should be on outcomes that address the core symptoms and behaviors of the disorder.
A nurse is looking after a client who has just received 1 mg of lorazepam IM for anxiety. What actions should the nurse take?
Explanation
Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.
Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.
Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.
Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.
A nurse is attending to a client being treated for posttraumatic stress disorder (PTSD). The client says, "I have trouble falling asleep and staying asleep." What recommendation should the nurse offer?
Explanation
Choice A reason: Napping during the daytime can interfere with nighttime sleep patterns and is generally not recommended for individuals with insomnia. It can create a cycle of fragmented sleep and may exacerbate difficulties in falling and staying asleep at night.
Choice B reason: While avoiding stimulating activities such as reading in the evening can be helpful for some individuals, it is not a universal recommendation. Reading can actually be a relaxing activity for many people and may help them wind down before bedtime.
Choice C reason: Dimming the screen on electronic devices can reduce exposure to blue light, which can interfere with the body's natural sleep-wake cycle. However, it is generally recommended to avoid the use of electronic devices altogether in the bedroom to promote better sleep hygiene.
Choice D reason: Meditation is a relaxation technique that can be beneficial for individuals with PTSD and sleep disturbances. It can help calm the mind, reduce stress, and prepare the body for sleep. Mindfulness meditation, in particular, has been shown to improve sleep quality and is a recommended practice for those experiencing insomnia.
A nurse is educating a client with an alcohol use disorder. What statement should the nurse make to assist in preventing relapse?
Explanation
Choice A reason: Listing the negative effects of alcohol use can help the client gain insight into the consequences of their actions and reinforce their motivation to remain sober. Reflecting on personal losses and health issues due to alcohol can be a powerful deterrent against relapse.
Choice B reason: While attending support group meetings can be beneficial, saying "as needed" may not provide the structured support necessary for preventing relapse. Regular attendance at support groups like Alcoholics Anonymous (AA) is often recommended for sustained recovery.
Choice C reason: Lorazepam is not typically prescribed to prevent relapse in alcohol use disorder due to its potential for abuse and dependence. Instead, medications like naltrexone or acamprosate may be considered to help maintain abstinence.
Choice D reason: Revisiting familiar places may trigger cravings and is generally not advised. Instead, clients are encouraged to avoid places associated with their past alcohol use to reduce the risk of relapse.
A nurse is examining the laboratory results of a client with schizophrenia who is on risperidone. Which finding should prompt the nurse to inform the provider?
Explanation
Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.
Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.
Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.
Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.
A nurse is educating a client who has just been diagnosed with Alzheimer's disease. Which treatment options should the nurse include in the teaching?
Explanation
Choice A reason: Initiating hospice care services is generally considered when the client is in the final stages of Alzheimer's disease and has a life expectancy of 6 months or less. Hospice care focuses on comfort and quality of life, rather than curative treatments. It's an option when the disease has significantly progressed, not typically at the time of initial diagnosis.
Choice B reason: Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain and is being studied as a potential treatment for improving cognitive status in Alzheimer's patients. However, it is not yet a standard treatment and is considered experimental.
Choice C reason: Barbiturate medications are not typically used to control anxiety in Alzheimer's patients due to the risk of dependency and the potential to worsen cognitive impairment. Other medications, such as selective serotonin reuptake inhibitors (SSRIs), are generally preferred for managing anxiety in these patients.
Choice D reason: NMDA receptor antagonists, such as memantine, are medications that can help delay cognitive symptoms in patients with moderate to severe Alzheimer's disease. They work by regulating the activity of glutamate, a neurotransmitter involved in learning and memory, which may be overactive in Alzheimer's disease.
A nurse is managing a client with Alzheimer's disease. What findings should the nurse anticipate?
Explanation
Choice A reason: An altered level of consciousness is not typically associated with Alzheimer's disease. Patients with Alzheimer's may experience confusion or disorientation, but changes in consciousness, such as stupor or coma, are not characteristic symptoms of the disease.
Choice B reason: Failure to recognize familiar objects, known as agnosia, is a common finding in Alzheimer's disease. As the disease progresses, the ability to recognize objects, faces, and even sounds can be impaired, which is a direct result of the deterioration of brain areas involved in processing sensory information.
Choice C reason: Excessive motor activity is not a common finding in Alzheimer's disease. While patients may experience restlessness, the disease often leads to a decrease in overall activity levels due to cognitive decline and the eventual difficulty with coordination and motor functions.
Choice D reason: Rapid mood swings can occur in Alzheimer's disease, but they are not as prominent as other cognitive symptoms. Mood changes in Alzheimer's are usually a result of the frustration and confusion experienced by the patient rather than a direct symptom of the disease itself.
A nurse is instructing the caregiver of a client with advanced Alzheimer's disease on home safety. Which statement from the caregiver shows that they understand the teaching?
Explanation
Choice A reason: Notifying law enforcement within 2 hours if the person cannot be found is important, but immediate action is usually recommended in such cases. The sooner the authorities are alerted, the better the chances of locating the individual safely.
Choice B reason: Giving the most recent photo to the police is a proactive step in case the person goes missing. It can help law enforcement quickly disseminate the information and aid in the search. However, this is a reactive measure rather than a preventive one.
Choice C reason: Placing a sliding bolt lock just above the doorknob can prevent the individual from wandering, which is a common and dangerous issue in people with advanced Alzheimer's disease. This measure helps ensure the person's safety by preventing unsupervised exits from the home.
Choice D reason: Ensuring the bedroom is dark while the person is sleeping may not be advisable. Adequate night lighting is important for preventing falls if the person needs to get up during the night. A completely dark room can increase the risk of injury.
A nurse is meeting with the partner of a client who recently passed away. The partner expresses guilt about not having done more for their loved one. What response should the nurse provide?
Explanation
Choice A reason: While sharing personal experiences can sometimes help in connecting with the grieving individual, it may also shift the focus away from the partner's feelings to the nurse's own experiences. It's important to keep the conversation centered on the partner's emotions and support needs.
Choice B reason: This response acknowledges the partner's feelings without judgment and opens the door for further conversation. It shows empathy and understanding, which are crucial in providing emotional support to someone who is grieving.
Choice C reason: Suggesting a grief counselor is a practical step, but it might be perceived as dismissive if offered too quickly. It's essential to first establish a supportive dialogue and understand the partner's readiness to seek additional help.
Choice D reason: Telling someone they shouldn't feel guilty can invalidate their feelings. Guilt is a common emotion in the grieving process, and it's important to acknowledge it and provide a safe space for the individual to express their feelings.
A nurse is getting a change-of-shift report for a group of clients at a mental health facility. Which of the following clients should the nurse evaluate for risks associated with sensory impairments?
Explanation
Choice A reason: Conversion disorder involves neurological symptoms like paralysis or blindness that are not explainable by medical evaluation. While these symptoms may mimic sensory impairments, they are psychological in origin and not due to actual sensory deficits.
Choice B reason: Mild anxiety disorder typically does not involve sensory impairments. Anxiety may cause heightened awareness or sensitivity to stimuli but does not result in a loss of sensory function.
Choice C reason: Narcissistic personality disorder is characterized by patterns of grandiosity, need for admiration, and lack of empathy. It does not include sensory impairments as a symptom.
Choice D reason: Clients with severe obsessive-compulsive disorder (OCD) may experience sensory overload due to heightened focus on certain stimuli, leading to stress and anxiety. Assessing for risks related to sensory impairments can help in managing their symptoms and improving their quality of life.
A nurse is looking after a client with social anxiety disorder who reports experiencing anxiety that interferes with their sleep. What recommendation should the nurse give?
Explanation
Choice A reason: Guided imagery is a relaxation technique that can help calm the mind and is beneficial for individuals with anxiety disorders. It involves envisioning a peaceful scene or series of experiences that can distract from anxious thoughts. This method can be particularly helpful before bedtime to ease the transition into sleep.
Choice B reason: Lying in bed and trying to force oneself to fall asleep can actually lead to increased frustration and anxiety, making it harder to fall asleep. It's recommended to leave the bed if unable to sleep and engage in a quiet activity until feeling sleepy.
Choice C reason: Eating a substantial meal before bed can lead to discomfort and disrupt sleep. It's better to have a light snack if needed and avoid heavy meals close to bedtime.
Choice D reason: Restricting sleep can exacerbate anxiety and is not recommended. It's important to maintain a regular sleep schedule and ensure adequate sleep to manage anxiety symptoms effectively.
A nurse is evaluating the sleep patterns of a client with an anxiety disorder. The client reports trouble sleeping on most nights. What recommendation should the nurse offer?
Explanation
Choice A reason: Watching television before bedtime can be stimulating and interfere with the ability to fall asleep. The blue light emitted by screens can also disrupt the body's natural sleep-wake cycle.
Choice B reason: Regular exercise, particularly when done earlier in the day, can help reduce anxiety and improve sleep quality. However, it's important to avoid vigorous exercise close to bedtime as it can be too stimulating.
Choice C reason: Consuming the evening meal too close to bedtime can cause indigestion and interfere with sleep. It's better to finish eating at least 2-3 hours before going to bed.
Choice D reason: Taking long naps, especially later in the day, can make it more difficult to fall asleep at night. If naps are necessary, they should be short and not too close to bedtime.
A nurse in an outpatient mental health facility is getting ready to give phenelzine to a client who has been on the medication for several years. The client reports having a grilled cheese sandwich and a banana for lunch and is feeling dizzy. Which vital sign should the nurse check first?
Explanation
Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.
Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.
Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.
Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.
A nurse is attending to a client who says, "I have had difficulty sleeping for the past few months." What response should the nurse give?
Explanation
Choice A reason: Engaging in stressful activities before bedtime can increase alertness and make it difficult to fall asleep. The nurse's recommendation to avoid stress before sleep is in line with good sleep hygiene practices that promote relaxation and readiness for sleep.
Choice B reason: Exercising too close to bedtime can be stimulating and may hinder the ability to fall asleep. It is generally recommended to finish exercising at least 3 hours before bedtime to allow the body to wind down.
Choice C reason: Taking long naps, especially in the afternoon, can disrupt nighttime sleep patterns. For individuals with insomnia, it is better to avoid naps or limit them to early in the day and for short durations.
Choice D reason: Watching television in bed can negatively impact sleep due to the light from the screen and the content, which can be stimulating. It is recommended to keep the bedroom environment conducive to sleep, which means no screens before bedtime.
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