ATI Psych – Flashcard
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A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect? a. The client has a heightened perceptual field. b. The client has difficulty concentrating c. The client reports shortness of breath. d. The client reports a sense of impending doom.
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b. The client has difficulty concentrating -- The nurse should expect the client who has moderate-level anxiety to have difficulty concentrating and focusing. This lack of concentration increases as the anxiety level escalates.
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A nurse is having a conversation with a client who frequently becomes angry and aggressive toward others. When the client becomes verbally abusive toward the nurse, which of the following statements by the nurse is appropriate? a. "I will take away privileges if you continue to be abusive." b. "I am leaving now but will return in a few minutes to see if you are calmer." c. "You have no right to talk like this and must stop yelling." d. "I don't talk angrily to you and you shouldn't talk that way to me."
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b. "I am leaving now but will return in a few minutes to see if you are calmer." ** An effective technique for handling verbal abuse is to leave the room immediately and return later to check on the client. The nurse should keep communication neutral and refrain from arguing with the client.
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A nurse in a mental health facility is assessing the use of defense mechanisms in a client who has bulimia nervosa. Which of the following client behaviors should the nurse identify as displacement? a. The client reports a headache each day when group therapy is scheduled. b. The client criticizes the nurse at each medication administration time. c. The client continually talks about the benefits of healthy eating habits. d. The client complains about the taste of the food.
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b. client criticizes nurse at each med administration time The nurse identifies the client's shifting of feelings r/t her medications to the nurse as displacement. Displacement - Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation
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Primary prevention
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Primary prevention promotes health and prevents mental health problems from occurring.
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Secondary intervention
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Secondary prevention focuses on early detection of mental illness.
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Tertiary intervention
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Tertiary prevention focuses on rehabilitation and prevention of further problems in clients who have previous diagnoses.
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A nurse is planning to develop a relationship with a new client. What are the phases of the nurse-client relationship?
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1. Recognize safety risks 2. Set the parameters of there relationship 3. Promote problem-solving skills 4. Summarize relationship goals
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A nurse is admitting a client who is experiencing alcohol withdrawal delirium. The nurse plans a room assignment. Which of the following clients is the most appropriate roommate for this client? a. Client with insomnia b. Client who has frequent visitors c. Client who is hyper vigilant d. Client who has depressive disorder
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D. Client who has depressive disorder A client experiencing alcohol withdrawal delirium requires uninterrupted rest; therefore, according to Maslow's hierarchy of needs, the client who has depressive disorder is most appropriate as a roommate because he will allow this client to get the most rest.
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A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory? a. "What year did you graduate from high school?" b. "What is your favorite childhood memory?" c. "What did you have for supper yesterday?" d. "What is today's date?"
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a. "What year did you graduate from high school?" When assessing a client's remote memory, the nurse should ask questions that determine the client's ability to remember things from the distant past. The nurse should ask questions that can be validated to ensure that the information is correct.
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Assessing immediate, recent, and remote memory
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Immediate: Ask the client to repeat a series of numbers or a list of objects. Recent: Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission. Remote: Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother's maiden name.
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Examples of overt statements
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"There is no point in living any longer." "I cant take it anymore" "I wish I were dead" "Everyone would be better off if I died"
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Examples of covert statements
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"I want to donate my organs to help others." "Soon no one will have to worry about me." "Everything will be better soon." "Things will never work out."
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When is a no-suicide contract discouraged?
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when the patient is still acutely agitated/angry - when the RN has made a trusting relationship.
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What food inhibits the metabolism of buspirone?
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grapefruit
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Is buspirone limited to a 90-day supply?
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No. It is not regulated under the Controlled Substance Act
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A nurse is caring for a client who is in hospice for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement? a. discuss spiritual issues in a conversational manner b. engage in a formal discussion of the pt's religious beliefs c. prompt pt to be specific when asking question related to his pwn spirituality d. offer suggestions based on personal spiritual briefs.
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a. discuss spiritual issues in a conversational manner - clients receiving end-of-life care prefer that discussions of spirituality occur in ordinary conversation.
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Who should engage in formal discussions regarding spiritual beliefs for end-of-life care?
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pastoral counselor or chaplain
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A nurse is planning to develop a relationship with a new client. Order the phases of the nurse-client relationship by placing all of the letters in the correct sequence:
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1. recognize saefty risks 2. set the parameter of the relationship 3. promote problem-solving skills 4. summarize relationship goals
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Pts at highest risk for suicide:
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- adolescents - young adult - older adult males - Native Americans - Pts w/ comorbidities: ** COMORBIDITIES: depression, anxiety, substance use, schizophrenia, eating disorders, bipolar disorder, personality disorders
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What are the risk factors for suicide in the older adult client?
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- Untreated depression** - loss of employment & finances - feelings of isolation - powerlessness - prior suicide attempt - change in functional ability - ETOH or other substances - loss of a loved one.
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biological risk factors for suicide:
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- Family Hx of suicide** - psychical disorders (AIDS, CA, cardiovascular disease, CVA, CKD, cirrhosis, dementia, epilepsy, head injury, Huntington's disease, & MS
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psychosocial risk factors for suicide:
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- sense of hopelessness - intense emotions (rage, anger, guilt) - poor interpersonal relationships at home, school, & work - developmental stressors (EX: those experienced by adolescents)
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A nurse is assessing a client who has been taking thioridazine for several days. The client reports hand tremors, drooling, and rigid extremities. Which of the following actions should the nurse take? a. Reassure client that thee effects are expected. b. Administer diazepam. c. Encourage deep breathing and relaxation d. Administer benzotropine.
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d. Give benztropine This client is experiencing extrapyramidal effects of thioridazine, which includes pseudoparkinsonism. Benztropine is a medication that counteracts these adverse effects. The nurse should notify the provider if extrapyramidal effects occur and obtain a prescription to alleviate the manifestations.
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What is Korsakoff's syndrome?
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secondary dementia caused by thiamine deficiency --> often caused by long-term ETOH abuse ** safety precautions
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PROTECTIVE factors against suicide:
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- feelings of responsibility toward family - current pregnancy - religious/cultural beliefs - overall satisfaction with life - presence of adequate social support - effective coping & problem-solving skills - access to appropriate medical care.
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A nurse is providing teaching to a client who has a new prescription for phenelzine. The nurse should teach the client that which of the following over-the-counter medications can cause a hypertensive crisis when taken concurrently with phenelzine? a. Acetaminophen b. Ranitidine c. Naproxen d. Pseuoephedrine
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D. Pseudoephedrine Pseudoephedrine interacts with MAOI medications and is therefore contraindicated. Ingesting products containing ephedrine along with phenelzine can precipitate a hypertensive crisis.
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A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine The nurse should instruct the client that which of the following blood tests should be performed periodically? a. Potassium b. Uric acid c. Glucose d. Calcium
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C. Glucose Clients taking quetiapine are at risk for abnormal glucose metabolism, which can result in diabetes mellitus. Therefore, the client should have glucose testing periodically.
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A nurse is caring for a client who has bipolar disorder and is taking valproic acid. Which of the following is the priority assessment finding? a. pt has not slept in 24 hrs b. states missing a dose yesterday c. evicted from apartment d.. fine hand tremors
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a. no sleep in 24 hrs ** indicates a manic state. A lack of sleep places the client at greatest risk for physical exhaustion and death
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A nurse is teaching a client to use cognitive reframing to manage the stress of public speaking. Which of the following statements by the client indicates an understanding of the teaching? a. "I have stayed up all night giving this speech in the mirror." b. "I know about the topic I've been asked to speak about." c. "I was asked to speak because I'm expected to know about the topic." d. "I will be done speaking in about an hour, and then I can relax."
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b. "I know about the topic I've been asked to speak about." ** A technique that replaces negative thoughts with positive self-statements is the correct use of cognitive reframing and will reduce the client's anxiety.
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A nurse is discussing simple restitution with the parents of a school-age child who has conduct disorder. Which of the following should the nurse recommend when discussing this behavioral management technique? a. Advising the parents to ignore the child's attention-seeking behavior if it is not dangerous b. Recommending a change in activity if the child begins to demonstrate frustration c. Establishing clear expectations for the child's behavior during meals d. Instructing the child to put away the books he threw during a period of aggression
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d. Instructing the child to put away the books he threw during a period of aggression ** The nurse recommends instructing the child to return the environment to its original state when using simple restitution as a behavioral management technique.
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A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue? a. An adolescent family member who questions parental authority b. A family with three generations in the same household c. Older children who are responsible for their younger siblings d. Two adults and their children from prior relationships in the same household
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c. Older children who are responsible for their younger siblings ** This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.
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A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? a. Have a family member present during treatment b.Increase fluid intake. c. Change position slowly. d. Wear sunglasses when outdoors.
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d. Wear sunglasses when outdoors. ** Light therapy, or phototherapy, can cause eye strain and sensitivity to light.
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A nurse is caring for a client who has recently been admitted with anorexia nervosa and needs to increase oral intake. Which of the following interventions should the nurse implement? a. Offer rewards for gaining weight. b. Initially increase daily intake to 2,500 calories. c. Temporarily decrease fiber intake. d. Restrict caffeine in the diet.
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d. Restrict caffeine in the diet. ** Caffeine should be avoided due to its stimulative and diuretic effects.
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A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? a. "I'm relieved now that my financial affairs are in order." b. "It is easier to talk about my feelings now." c. "Suddenly I have enough energy to do anything I want." d. "Thank you for always taking such good care of me."
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b. "It is easier to talk about my feelings now." *** When clients express their feelings, this indicates a positive treatment outcome.
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A nurse is caring for a client who has a history of aggressive behavior. The client is playing cards and throws the cards at other clients. Which of the following interventions is appropriate in this situation? a. Ask the client to express how he is feeling. b. Admonish the client for inappropriate behavior. c. Explain the rules of the unit to the client. d. Take the cards away from the client.
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a. Ask the client to express how he is feeling. ** To prevent further escalation of the client's anger, the nurse should use therapeutic communication to determine what the client is feeling
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A nurse is facilitating a community meeting for inpatient clients. One client is constantly talking and using up the majority of the group's time. Which of the following interventions should the nurse implement? a. Tell the client that he must talk less or he will be removed from the meeting. b. Focus on other group members and ignore the client who is doing all the talking. c. End the group meeting and take the client aside to discuss his behavior. d. Ask group members to discuss their feelings about this client's monopolizing behavior.
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d. Ask group members to discuss their feelings about this client's monopolizing behavior. ** This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.
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A nurse is working with a group of older adult clients at an independent living facility who are discussing their plans for family reunions. Which of the following statements by a group member warrants further assessment by the nurse? a. "I should have taken the time to enjoy the reunions with my wife when she was alive." b. "I wish that we would have had family reunions when I was younger, so I could have enjoyed them more." c. "I'd like to go back to the days when my children were small and enjoyed spending time playing with their cousins." d. "I'm not going to the reunion because no one asked me to help plan it."
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d. "I'm not going to the reunion because no one asked me to help plan it." ** Feelings of uselessness are an early finding of depression in older adults.
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What is dysthymic disorder?
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milder form of depression w/ early onset (childhood/adolescence) & lasts at least 2 years in length in adults (1 year length for children) ** contains at least 3 clinical findings of depression and may become major depressive disorder later in life
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Therapeutic procedures for major depressive disorder:
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- electroconvulsive therapy (require specially trained RN to monitor before & after) - Transcranial magnetic stimulation (indicated for depression which is resistant to other forms of trmt) - Vagus nerve stimulation (depression that is resistant to at least 4 antidepressant meds)
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What is light therapy used for?
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First-line trmt for seasonal-affective disorder * light therapy inhibits nocturnal secretion of melatonin * exposure to the face of 10,000lux light box 30 mins/day, once or in two divided doses * wear sunglasses outdoors. Causes eye sensitivity
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3 medications for aggressive and impulsive behavior:
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olanzapine ziprasidone (Geodon) haloperidol
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haloperidol nursing considerations:
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- monitor for parkinsonian and anticholinergic reactions - keep pt hydyrated - VS - test for muscle rigidity = NMS
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Side effects of haloperidol:
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- parkinsonian rxn - anticholinergic effects - photosensitivity - shuffling gait - dry mouth - blurred vision - orthostatic hypotension - EPS - sedation - constipation
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oppositional defiant disorder can develop into:
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conduct disorder
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What is scapegoating?
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A member of the family with little power is blamed for problems within the family. For example, one child who has not completed his chores may be blamed for the entire family not being able to go on an outing
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What is triangulation?
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A third party is drawn into the relationship with two members whose relationship is unstable. For example, one parent may develop an alliance with a child, leaving the other parent relatively uninvolved with both.
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Describe multigenerational issues:
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These are emotional issues or themes within a family that continue for at least three generations, such as a pattern of substance use or addictive behavior when the family is under stress, dysfunctional grief patterns, triangulation patterns, divorce.
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Diet plan for pt w/ anorexia & bulimia:
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- consider pt's preferences & ability to consume food - a structures & inflexible eating schedule at start of therapy - small, frequent meals - high fiber - LOW SODIUM (to prevent fluid retention) - limit fatty/greasy foods - give multivitamin & mineral supplement - avoid caffeine
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A nurse is counseling a client who seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make? a. "Did I say something wrong that made you feel tense?" b. "Do you often feel tense when you are talking to a health care provider?" c. "What were we discussing when you began to feel uncomfortable?" d. "It is ok to feel nervous during our counseling sessions."
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c. "What were we discussing when you began to feel uncomfortable?" -- The nurse should use the therapeutic technique of focusing, which promotes discussion about a specific topic. This technique helps identify the cause of the client's feelings and promotes further communication.
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A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of the following actions should the nurse take first? a. Provide the client with information about a 12-step recovery program. b. Encourage the client to accept responsibility for his alcohol use. c. Teach the client alternate coping mechanisms to use in place of alcohol. d. Ask the client to complete a CAGE Questionnaire.
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d. Ask the client to complete a CAGE Questionnaire. -- The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the client's alcohol use. Use of a CAGE Questionnaire is helpful to determine the impact of alcohol use on the client's life.
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A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make? a. "Aren't you worried about the safety of your children?" b. "Can you identify your behaviors that provoke your partner?" c. "The next time this occurs, what might you do to ensure your safety?" d. "You need to remove yourself and your children from the abusive situation."
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c. "The next time this occurs, what might you do to ensure your safety?" -- The nurse should use the therapeutic communication technique of encouraging formulation of a plan of action. With this technique, the nurse encourages the client to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the client to develop a safety plan, which includes information about shelters, so that she has the information if she chooses to leave in the future.
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A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make? a. "Many people feel this way when they first start treatment." b. "In other words, you seem to be saying that you feel unworthy of help." c. "You'll feel better once you get up and have some breakfast." d. "I disagree with your feeling that you are not worth my time."
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b. "In other words, you seem to be saying that you feel unworthy of help." -- use the therapeutic technique of paraphrasing to clarify the client's statement and promote further communication.
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A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? a. Obtain a PRN prescription for restraints from the client's provider. b. Visually observe the client every 10 min until restraints are removed. c. Ensure that three fingers can fit between the restraint and the client's wrist. d. Document the client's behavior every 15 min while restraints are in place.
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d. Document the client's behavior every 15 min while restraints are in place. -- The nurse should plan to document the client's behavior every 15 min while restraints are in place. This frequent documentation meets the legal requirement for use of restraints; helps provide for prompt identification of complications related to restraint use; and helps ensure that restraints are removed as soon as possible, depending on the client's behavior.
