Fundamentals
A nurse is reviewing treatment alternatives for managing a client's behavior. The nurse should identify that which of the following examples describes the least restrictive alternative?
A. Administering a prescribed sedative to calm the client.
B. Using physical restraints to prevent the client from harming themselves or others.
C. Asking the client to return back to their assigned room.
D. Placing the client in secluded quite room to prevent harm to themselves.
What is Asking the client to return back to their assigned room.
A patient is experiencing bouts of major depression with episodic occurrence of hypomania. What type of bipolar disorder the patient is manifesting?
Bipolar 2
A nurse is discussing common misconceptions regarding clients who have substance use disorder. The nurse should include which of the following as a potential negative result of providers believing that addiction is the client's own fault?
A. The client may avoid seeking outpatient counseling services.
B. The provider may have unrealistic expectations of the client's recovery timeline.
C. The client may refuse group therapy sessions.
D. The provider may deny care or deliver poor quality of care.
D. The provider may deny care or deliver poor quality of care.
Rationale:
When healthcare providers hold the misconception that substance use disorder is entirely the client's fault, this can lead to stigmatization, bias, and discrimination in care. Providers may unconsciously or consciously deny services, or deliver lower-quality care, because they view the condition as a personal failing rather than a chronic medical condition. This attitude can contribute to worse outcomes for the client. The other options are not directly related to the impact of provider bias; while clients may have different preferences or experiences in treatment, the most harmful consequence of provider misconceptions is compromised care quality.
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
A. Blunt affect
B. Delusions
C. Anhedonia
D. Hallucinations
E. Poor judgment
A. Blunt affect
C. Anhedonia
Rationale:
Negative symptoms of schizophrenia refer to the absence or reduction of normal functions, such as diminished emotional expression and motivation. Blunted or flat affect (lack of emotional expression) and anhedonia (inability to experience pleasure) are common negative symptoms.
A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.)
10 mL
A nurse is discussing the difference between mental illness and mental health with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?
A. Mental illness and mental health are the same thing and can be used interchangeably.
B. Mental health only refers to the absence of any mental health disorders.
C. Mental health is a continuum, ranging from optimal well-being to severe mental illness.
D. Mental illness refers to a state of well-being and the absence of any psychological disorders.
What is Mental health is a continuum, ranging from optimal well-being to severe mental illness.
A suicidal client with a history of manic behavior is admitted to the emergency department. The client’s diagnosis is documented as bipolar 1 disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder?
A. There is no history of major depression in the client’s family.
B. The client has experienced a manic episode in the past.
C. The physician does not believe the client is experiencing major depression.
D. The client does not exhibit psychotic symptoms.
B. The client has experienced a manic episode in the past.
A nurse is educating a client and their partner about substance use. Which of the following explains why it is crucial to identify early warning signs of substance use?
A. Recognizing early warning signs allows the client's family to stage an intervention run by family members and other loved ones.
B. Recognizing early warning signs allows the client time to institute or make changes to end-of-life legal documents, such as a living will.
C. Recognizing early warning signs allows law enforcement to make arrests that lead to forced treatment.
D. Recognizing early warning signs can lead to early intervention and better outcomes.
D. Recognizing early warning signs can lead to early intervention and better outcomes.
Rationale:
Identifying early warning signs of substance use is critical for early intervention, which can significantly improve treatment outcomes. Early recognition provides an opportunity for healthcare providers, clients, and their support systems to address substance use before it becomes more severe or life-threatening. This can lead to more effective interventions, better engagement in treatment, and an increased chance of recovery. The other answer choices either focus on incorrect or unrelated outcomes of early recognition of substance use warning signs.
A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?
A. Hallucination
B. Illusion
C. Delusion
D. Obsession
C. Delusion
Rationale:
A delusion is a false belief that is firmly held despite clear contradictory evidence. The client's belief that a government agency is attempting to capture them is an example of a paranoid delusion, which is commonly seen in various mental health disorders, including depression with psychotic features.
The nurse is caring for a client with schizophrenia. The physician has prescribed haloperidol (Haldol) 5 mg IM STAT, followed by 3 mg PO three times daily, along with benztropine 2 mg PO twice daily as needed. What is the primary reason haloperidol is being prescribed?
A. To alleviate psychotic symptoms
B. To help the client sleep
C. To prevent neuroleptic malignant syndrome (NMS)
D. To minimize extrapyramidal symptoms (EPS)
A. To alleviate psychotic symptoms
A nurse is educating a client about mental illness and the client asks, "Why do some people who take medications experience resolution of clinical manifestations of their mental illness while other people experience relapses or worsening clinical manifestations?" Which of the following statements should the nurse make?
A. "It’s uncommon to experience manifestations after a few days of medication treatment."
B. "The willpower of the client determines manifestations remission."
C. "Adhering to a medication regimen will likely cure mental illness."
D. "The brain's ability to adapt is very individual and plays a role in symptom severity."
D. "The brain's ability to adapt is very individual and plays a role in symptom severity."
A client who is prescribed lithium carbonate is being discharged from inpatient care. What should the nurse teach this client?
Exercise, sodium, hydration. Lithium is a mood stabilizer, and maintaining proper hydration is crucial while taking this medication because dehydration can lead to increased lithium levels, resulting in toxicity. It's important that patients taking lithium avoid dehydration and maintain a consistent intake of fluids and sodium.
A nurse is caring for a client who reports spending 12 hr daily playing video games online. The client has spent a significant amount of money betting on these games. They lost their job due to missed work, and they filed for bankruptcy because of their gambling debts. Their partner was supporting them financially until the partner left the client out of frustration with their behavior. Which of the following manifestations of non-substance addiction is characteristic of the client's behavior?
A. Loss of control over behavior
B. Inability to form relationships
C. Physical withdrawal symptoms
D. Need for an emotional support system
A. Loss of control over behavior.
Rationale: One manifestation of non-substance addiction is continuing the behaviors even though they have negative consequences.
A nurse is caring for a client diagnosed with schizophrenia who is reporting hearing voices. Which of the following actions should the nurse take?
A. Respond to the client as though the voices are real.
B. Instruct the client to challenge the voices they are hearing.
C. Ask the client open-ended questions about what they are hearing.
D. Inform the client that the voices are not real and should be ignored.
C. Ask the client open-ended questions about what they are hearing. Asking open-ended questions about the hallucination helps the nurse gather important information about the client’s experience, assess their mental status, and determine the risk level, making this the correct action.
A staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action?
A. Agree to not report the incident if the coworker promises to report themselves to the supervisor.
B. Report the incident to the appropriate person in the chain of command right away.
C. Report the incident to the other RNs on the shift.
D. Agree to not report the incident if the coworker seeks treatment.
B. Report the incident to the appropriate person in the chain of command right away.
Rationale:
The nurse has a legal and ethical obligation to report the incident immediately to the appropriate supervisor or person in the chain of command. Failing to report this behavior could put patients at risk and violate professional standards. It is not appropriate to agree to withhold reporting under any circumstances, including promises of self-reporting or seeking treatment.
A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home?(Select All that Apply.)
Necklace
Lace-up tennis shoes
Nylon socks
Glass framed picture of the client's partner
Cotton underwear
Necklace, Lace-up tennis shoes, Glass framed picture of the clients partner
A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?
A. Provide the client with a detailed, lengthy explanation of the unit policies.
B. Avoid discussing the unit routine to prevent overwhelming the client.
C. Provide information slowly in simple, concise terms.
D. Have the client review the unit's rules and policies independently.
C. Provide information slowly in simple, concise terms.
A nurse is creating a presentation on alcohol withdrawal syndrome. Which of the following symptoms should the nurse highlight as commonly associated with alcohol withdrawal?
A. Auditory or visual hallucinations
B. Hypotension
C. Muscle stiffness
D. Bradycardia
A. Auditory or visual hallucinations
Rationale:
Alcohol withdrawal symptoms typically begin within hours of cessation and can range from mild to severe. Hallucinations (visual, auditory, or tactile) are a significant and potentially severe symptom of alcohol withdrawal, often occurring within 12-24 hours after the last drink. In contrast, hypotension (low blood pressure) and bradycardia (slow heart rate) are not common in alcohol withdrawal; instead, hypertension (high blood pressure) and tachycardia (rapid heart rate) are more likely. Muscle stiffness is not a primary feature of alcohol withdrawal, though muscle tremors and seizures can occur in more severe cases.
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?
A. "You are mistaken. Nobody is lying about you or trying to poison you."
B. "You seem to be having very frightening thoughts."
C. "Why do you think you are being lied about and poisoned?"
D. "Who is lying about you and trying to poison you?"
B. "You seem to be having very frightening thoughts."
Rationale:
When responding to a client who is experiencing delusions, the nurse should avoid directly confronting or validating the delusions. Instead, the nurse should focus on the client's emotional experience, acknowledging the feelings of fear or distress. This therapeutic approach helps build trust and provides comfort without reinforcing the delusion.
A nurse is caring for a client prescribed clozapine. What lab should the nurse prepare to discuss with the client?
What is a complete blood count (CBC) with a focus on absolute neutrophil count (ANC)
A nurse on a mental health unit is discussing the concepts of competency and capacity with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concepts?
A. "Competency is determined by a healthcare provider, while capacity is determined by the court."
B. "A client must have both competency and capacity to provide informed consent for treatment."
C. "Competency refers to a legal decision, while capacity refers to a clinical assessment."
D. "If a client lacks capacity, they automatically lose their competency as well."
C. "Competency refers to a legal decision, while capacity refers to a clinical assessment."
A nurse is caring for a client who ingested a selective serotonin reuptake inhibitor (SSRI) and St. John's Wort. Which of the following findings should the nurse identify as being consistent with serotonin syndrome?
A. Dilated pupils and muscle rigidity
B. Tinnitus and jerking movements
C. Suicidal Ideations
D.Pill rolling movements and drooling
A. Dilated pupils and muscle rigidity
A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?
A. Pinpoint pupils
B. Tachypnea
C. Hypertension
D. Elevated heart rate
A. Pinpoint pupils
Part of the nurse's continual assessment of the patient taking antipsychotic medications is to observe for extrapyramidal symptoms (EPS). Examples include which of the following?
A. Amenorrhea, gynecomastia, decreased libido
B. Elevated blood pressure, severe occipital headache, stiff neck
C.Muscular weakness, rigidity, tremors, facial spasms
D. Dry mouth, blurred vision, urinary retention, orthostatic hypotension
C.Muscular weakness, rigidity, tremors, facial spasms
What are the symptoms consistent with extrapyramidal symptoms (EPS) in a client taking antipsychotic medication?
What is Akathisia (restlessness and inability to stay still), dystonia (muscle spasms and abnormal postures), pseudoparkinsonism (tremors, shuffling gait, and rigidity), and tardive dyskinesia (repetitive involuntary movements such as lip-smacking and grimacing).