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Mental Health ATI – Assessment A

question

A nurse in mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first?
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Accompany the client to a quiet room. (Greatest risk for this client is injury due to severe anxiety. Therefore, first action nurse should take is to stay with client and bring him to a room with minimal stimuli.)
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A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with PTSD? (Select all that apply)
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Distressing dreams Difficulty concentrating Exaggerated startle response
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A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider?
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Shuffling gait. (Clinical findings of pseudoparkinsonism such as shuffling gait may occur 5hr – 30 days after beginning treatment. The client should notify the provider who might prescribe an anti parkinsonism agent.)
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A home health nurse is assessing an older adult client who lives alone. Which of the following findings should indicate to the nurse that the client is experiencing delirium?
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Sudden onset. (Clients usually develop delirium suddenly over hours to days.)
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A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor?
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Urinary retention.
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A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. Client’s morning lithium level is 1.5 mEq/L. Which of the following additional laboratory data has the highest priority? a) Serum erythrocyte sedimentation rate 18 mm/hr b) Hemoglobin 15 g/dL c) serum T4 5 mcg/dL d) Serum sodium 125 mEq/L
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Serum sodium 125 mEq/L (In the presence of low sodium levels, renal excretion of lithium is reduced and client is at risk for lithium toxicity. Therefore, this finding is highest priority because it places client at greatest risk for injury.)
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A nurse is caring for a client who has a history of substance use and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?
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Do not administer the lorazepam. (Clients who are involuntarily admitted retain the right to refuse treatment.)
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A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth.)
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1.5 mL
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A nurse is developing a discharge plan for a client who has a history of gambling dependency and includes participation in support group. The nurse should tell the client that which of the following is the purpose of attending a support group?
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Provide assurance that others have a similar problem. (Participating in a support group with other individuals who have similar problems will show the client that he is not the only one with this problem. The client can learn alternative ways to solve problems that other members of the group have also experienced.)
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A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy (ECT). Provider needs to explain procedure to client in order to obtain informed consent. Which of the following actions should the nurse take?
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Request a professional interpreter to translate.
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Nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the eaching?
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Right to treatment ensures individualized care.
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Nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?
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A 35-year-old who has major depressive disorder.
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A nurse is caring for client whose child recently died in a motor vehicle crash and states, “I just want to join him.” Which of the following is the nurse’s priority response?
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“Are you thinking about harming yourself?” (Greatest risk is self-injury; priority is therefore to ask client if she has plans for self-harm)
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A nurse is assessing a client in the ED. Client appears agitated, his blood pressure is 152/94 mm Hg, his HR is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances?
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Cocane (cocaine intoxication causes tachycardia, elevated BP, dilated pupils, and agitation. These physiological findings suggest cocaine intoxication).
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A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor?
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Blood glucose (risperidone can cause diabetes mellitus to develop; therefore, nurse should plan to monitor client’s blood glucose level when taking this medication)
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Nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest?
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Roasted chicken. (contains little to no tyramine and is an appropriate menu choice for client who is taking tranylcypromine, an MAOI)
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A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider?
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Coarse hand tremor. (Coarse hand tremor can indicate toxicity and the client should report this finding to the provider immediately)
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A client is experiencing a situational crisis. Which of the following findings should the nurse expect?
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Client recently lost a grandparent in a motor vehicle crash. (Client experiences a situational crisis when an unexpected event occurs.)
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A nurse is assessing a client in the ED who is brought in by a caregiver. The caregiver states the client fell recently. The nurse observes bruises on the client’s abdomen, back, and legs suspects abuse. Which of the following actions should the nurse take first?
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Check the client for other s/s of abuse. (First action the nurse should take using nursing process is to assess client. Therefore, first action the nurse should take is to check client for further s/s of abuse.)
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A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the highest priority for the nurse to report to the treatment team?
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Giving away possessions (indicates client is at greatest risk for suicide; therefore, priority finding).
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A nurse is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self-directed injury or injuring others?
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Command hallucinations (a client who has schizophrenia and is experiencing command hallucinations may be told to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at greatest risk for self-directed injury or injuring others).
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A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following is an appropriate action by the nurse?
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Ask the family member if she has any thoughts or questions about this portion of the treatment plan. (Nurse’s action involves the family member and allows her a venue to communicate about the client’s medication treatment plan.)
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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which medications should the nurse administer?
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Chlordiazepoxide (prevents withdrawal symptoms)
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Nurse is meeting with client being discharged from substance abuse disorder treatment program. Which of the following client statements indicates the client is planning to make a lifestyle change?
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I will change my route going home from work so I don’t pass my favorite bar. (Client takes responsibility for behavior and uses adaptive coping mechanisms to avoid threats to recovery)
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When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the nurse should first
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inform the client that her admission will be confidential (nurse should inform client about confidentiality during orientation phase of the nurse-client relationship; therefore, this is the first action the nurse should take).
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A nurse working in an outpatient clinic is assessing a university student who says he feels restless and irritable before taking an exam. the nurse should assess the clinical findings as which of the findings.
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Mild anxiety. (clinical findings include restlessness, irritability, nail biting, fidgeting)
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Nurse caring for a client who has borderline personality disorder. Which of the following is priority goal when planning care for this client?
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Client will refrain from self-mutilation (greatest risk is injury to self and others)
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Nurse is planning discharge teaching with family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?
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Early identification of changes such as decreased social involvement is important (decreased social involvement is manifestation of depression and early identification of findings can lead to early intervention)
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Nurse is interviewing an older adult client in an outpatient mental health clinic. Which of the following strategies should the nurse use?
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Conduct interview in a private area (to ensure confidentiality and promote trust)
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Nurse is communicating with a client in an inpatient mental health facility. Which of the following demonstrates the use of active listening?
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Attention to body language (use of active listening involves identifying verbal and nonverbal communication of client, which includes attention to body language)
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A nurse is performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse. Which of the following statements indicates the greatest potential risk factor for abuse?
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My son enjoys a couple of drinks each night to unwind (substance abuse increases the likelihood of family violence; use of alcohol by this client’s adult son places this client at greatest risk for abuse)
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Nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following characteristics of this disorder should the nurse include in the teaching?
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Language delay (child who has autism spectrum disorder usually has language delay)
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Nurse is conducting a group therapy session for clients who have bipolar disorder. One of the clients begins bragging and dominating the conversation. Which of the following actions should the nurse take?
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Tell the client to calm down or he will be dismissed from the session (provide clear expectations and set limits for the client; therefore, appropriate action for the nurse to take)
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A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions in the highest priority?
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Use a therapeutic holding technique. (Greatest risk to this child and others is harm; therefore, nurse’s priority intervention is to use a therapeutic holding technique to deescalate the behavior and prevent injury)
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Nurse is caring for a client who has schizophrenia. The treatment plan is for client to increase his autonomy from his parents. Prior to discharge, the nurse should plan to
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schedule a family conference (allows nurse to work with client and family to make action plan for increased autonomy; this is a positive step for client prior to discharge)
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A nurse is caring for a client with dementia. Which of the following interventions is useful for orienting a client to reality?
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Place a large wall calendar in the client’s room. (orient to reality of day, month, and year)
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Nurse is obtaining a health history during client’s admission to mental health facility. Client begins to talk on her cell phone. When client finishes talking, she reports to the nurse, “that was the president, I leave in the morning on my new mission.” Which of the following is an appropriate response?
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How long have you been having conversations with the president? (therapeutic response because it allows nurse to further evaluate client’s delusion)
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During a client’s initial interview in a mental health inpatient setting, the nurse recognizes that the client maintains eye contact and leans toward him. Nurse should conclude that the client
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is beginning to trust the nurse. (attending behaviors communicate that the client feels the nurse respects her; client’s posture demonstrates that she is interested in interview and is reflection of her feeling that nurse is trustworthy and deserves her attention)
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Nurse is developing a plan of care for for client who exhibits anger, aggression, and violent behavior on the unit. Priority nursing intervention is to
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create a large, personal space (greatest risk is injury to client, staff, and others; therefore, creating a large, personal space between the nurse and client to ensure safety for nurse and client is priority intervention)
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Nurse is facilitating a bereavement support group and observes that one member remains silent, even after attending several sessions. Which of the following strategies should the nurse use to encourage the member’s participation?
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Divide the group into pairs to discuss a topic, then summarize the discussion to the group (this is one of several strategies the nurse can use to draw a silent member into group participation).
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Nurse in a provider’s office is talking with a client who has diabetes mellitus and an HbA1c of 8.5%. Client states that she is under a lot of stress and that she doesn’t want to talk about her diabetes mellitus right now. Based on these comments, the nurse should note that the client is demonstrating which of the the following defense mechanisms?
answer

Suppression (client is suppressing her feelings about dealing with having chronic illness when she consciously denies her current health status).
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Client recently diagnosed with bipolar disorder is placed in a room with client who has severe depression. Client who has depression reports to the nurse, “That man in my room never sleeps and he keeps me up, too.” Which of the following is an appropriate intervention for the nurse to take?
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Move client who has bipolar disorder to private room. (Clients who have bipolar disorder can disrupt therapeutic milieu for other clients; therefore, nurse should move client to a private room.)
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A nurse is conducting a counseling session with a client who has depression. Which of the following statements by the client indicates the client is demonstrating transference?
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I feel like you talk to me like my sister does (experiencing feelings toward nurse that she had for important person in her life)
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Nurse is admitting client who has depression to an inpatient mental health facility. Client states that he feels so bad that he is certain he will never be discharged. Which of the following is an appropriate response?
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You seem concerned about getting out of the hospital (making observations and encouraging client to talk further about concerns)
question

Nurse caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). Provider has explained the procedure to the client. Which of the following statements made by the client indicates a need for further teaching?
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This procedure can increase my risk for developing Parkinson’s disease (not an expected adverse effect of ECT; therefore, this statement indicates a need for further teaching)
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During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. Client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following is an appropriate action by the nurse?
answer

Assess the client for evidence of perceptual disturbance (assess situation to determine if the client is hallucinating or misperceiving external stimuli [experiencing illusions]).
question

A nurse is caring for a client for a client who has alcoholic cardiomyopathy. Which of the following laboratory values should the nurse expect?
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Increased creatinine phosphokinase (CPK) [increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy]
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Nurse is planning to teach a group of parents about healthy adolescent behavior. Which of the following information should the nurse include?
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Exhibits a realistic self-concept (mentally healthy adolescent usually exhibits a realistic self-concept).
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Nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom of this disorder?
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Flat affect (is the absence of emotion- this is a negative symptom because client demonstrates absence of normal emotions and behaviors)
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Nurse is preparing to discharge an older adult client, who attempted suicide, to his home where he lives alone. Client also has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all)
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Occupational therapy (to assist with ADLs) Meal delivery services (necessary due to difficulty performing ADLs) Physical therapy (to assess mobility needs and assist with ADLs) Home health services (provide nursing assessment of client’s physical and mental status, as well as assistance with ADLs
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While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?
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Client needs excessive external input to make everyday decisions
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Nurse is admitting an adolescent client who has anorexia nervosa. Which of the following clinical findings should nurse expect?
answer

Amenorrhea (clinical finding of anorexia nervosa caused by low weight)
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Nurse is caring for client who is taking chlorpromazine for schizophrenia. Which if following assessment findings indicates client is experiencing extrapyramidal adverse effects?
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Lip smacking and tongue rolling (indicate long-term extra-pyramidal side effects associated with typical antipsychotic medications)
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Nurse is providing teaching to client who is to be discharged from inpatient detoxification program and plans to attend Alcoholics Anonymous. Which of the following statements by client indicates understanding of the teaching?
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I will use peer support to maintain my abstinence (AA encourages recovery through peer support)
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A nurse is leading a group therapy session when a client becomes agitated and yells, “Listening to all of you is making me worse!” Which of the following is an appropriate response?
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You sound angry and frustrated. Tell us more about how you are feeling. (Nurse is making observations and exploring client’s feelings to demonstrate caring)
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Nurse is admitting a client to inpatient unit who is in acute stages of schizophrenia. Nurse observes the following findings: restlessness, pacing with clenched fists, eyes darting to one side, and muttering. Which of the following interventions should the nurse initiate?
answer

Stay with the client in a client setting (decreases environmental stimuli – reduces client’s agitation, allowing nurse to develop therapeutic relationship with client and make client feel safe)
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Nurse working in clinic is assessing client whose partner died 4 mos. ago. Which of the following statements indicates client is at risk for complicated grief?
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I feel so empty without my wife; it’s hard to get up every morning. (When a client has difficulty carrying on normal activities following a loss, it is an indication that there is a risk for complicated grief)
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Nurse is caring for client who has schizophrenia and is threatening to harm others on the unit. Provider prescribes haloperidol and seclusion. Which of the following should be included in plan of care?
answer

Offer client food every hour (nurse should offer food to client in seclusion every hour)
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Nurse is caring for client in mental health facility who has recently started a new prescription for valproic acid. For which of the following should the nurse monitor to determine effectiveness of the medication?
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Client has decreased episodes of pressured speech (monitor for decreased episodes of pressured speech, insomnia, grandiose thoughts and hyperactivity for a client who has mania and is taking valproic acid)
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Nurse is caring for client who has anorexia nervosa. Which of following criteria requires hospitalization?
answer

Temperature of 35.6 C (96.1 F) (severe hypothermia – temp lower than 96.8F – due to loss of subq tissue or dehydration requires hospitalization)