PN Mental Health Online Practice 2020 B ALL ANSWERS 100% CORRECT SPRING FALL-2022 LATEST SOLUTION GUARANTEED GRADE A+

A nurse is reinforcing teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that eating foods high in tyramine can cause which of the following adverse reactions with this medication? A. Hypertensive crisis B. Serotonin syndrome C. Hearing loss D. Urinary incontinence A. Hypertensive crisis RAT: Tyramine can cause severe hypertension in clients who are taking phenelzine, a monoamine oxidase inhibitor. Manifestations include palpitations, stif f neck, headache, nausea, vomiting, and elevated temperature. A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan? The client will participate in assertiveness training. The client will discuss feelings that cause hostility. The client will describe an activity they found enjoyable. The client will dress in a manner appropriate for the setting and temperature. The client will discuss feelings that cause hostility. RAT: Clients who have antisocial personality disorder are frequently aggressive and are at risk for injuring themselves or others. A short-term goal for these clients should be to discuss feelings that precipitate aggression or hostility. The nurse is assisting with an admission have a client who has eating disorder. During data collection, which is the following to the nurse identify as manifestations of bulimia nervosa? SOA A. Tooth erosion B. Hand calluses C. Lanugo D. Amenorrhea E. Hypokalemia A. Tooth erosion B. Hand calluses E. Hypokalemia RAT: Tooth erosion is a manifestation of bulimia nervosa that results from self-induced vomiting. Hand calluses are a manifestation of bulimia nervosa that results from self-induced vomiting. Lanugo is a manifestation of anorexia nervosa that results from starvation. Amenorrhea is a manifestation of anorexia nervosa that results from extreme weight loss. Hypokalemia is a manifestation of bulimia nervosa that results from volume depletion due to self-induced vomiting or excessive diuretic and laxative use. A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? A. Potassium 4.0 mEq/L B. Lithium 0.9 mEq/L C. BUN 12 mg/dL D. Sodium 132 mEq/L D. Sodium 132 mEq/L RAT: The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider. A nurse in a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? A. Weigh the client at night prior to bedtime. B. Offer liquid supplements to the client. C. Encourage the client to gain 2.3 kg (5 lb) per week. D. Observe the client for up to 30 min after meals. B. Offer liquid supplements to the client. RAT: The nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when they are first admitted. The nurse should observe the client for at least 1 hr after meals to prevent the client from throwing away, hiding, or purging food. A nurse is contributing to plan of care for a school-age child who has attention deficit hyperactivity disorder. Which of the following interventions should the nurse recommend? A. Avoid the use of humor when managing the child's disruptive behaviors. B. Instruct the child to apologize for behavior that negatively affects others. C. Maintain a scheduled plan of activities regardless of the child's behavior. D. Administer methylphenidate PRN when the child exhibits disruptive behavior. B. Instruct the child to apologize for behavior that negatively affects others. RAT: The nurse should recommend performing simple techniques to manage the child's behavior, including making amends. This technique includes apologizing to others when the client's behavior has a negative effect. A nurse is reviewing laboratory values for a client who has anorexia nervosa. Which of the following results should the nurse expect? A. Potassium 3 mEq/L B. Phosphorus 3.5 mg/dL C. Magnesium 1.8 mEq/L D. Cholesterol 165 mg/dL A. Potassium 3 mEq/L RAT: The nurse should expect a client who has anorexia nervosa to have hypokalemia, which is indicated by a decreased potassium level. This value is below the expected reference range of 3.5 to 5 mEq/L. A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Decreased heart rate C. Slurred speech D. Rhinorrhea A. Elevated blood pressure RAT: Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to 12 hr of cessation of alcohol ingestion. A nurse is caring for a client who recently lost their child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? A. "Are there times when you feel more upset than others?" B. "Have you had any thoughts of harming yourself?" C. "What type of support system do you currently have?" D. "During difficult times in the past, what did you do to cope?" B. "Have you had any thoughts of harming yourself?" RAT: The greatest risk to this client is self-injury due to suicide. Asking whether or not the client has plans to hurt themselves is the most important question for the nurse to ask at this time because a positive response can alert the nurse to the need for suicide precautions and intervention. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider? A. Fasting blood glucose B. Temperature C. WBC count D. Heart rate C. WBC count RAT: The nurse should identify that a WBC count of 3,000/mm3 is below the expected reference range of 5,000 to 10,000/mm3. The nurse should identify that clozapine can cause agranulocytosis, a decrease in white blood cells, which can be life threatening. Therefore, the nurse should withhold the client's medications and notify the provider of this finding. A nurse is collecting data from a client whose home was destroyed by a fire. Which of the following responses should the nurse make first? A. "Are you experiencing feelings of hopelessness?" B. "Is there someone I can call for you?" C. "It might be helpful for you to attend a support group." D. "Now is a good time for you to use relaxation breathing." A. "Are you experiencing feelings of hopelessness?" RAT: When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe. The nurse should collect data about the client's feelings to determine if the client is having feelings of hopelessness or suicidal ideations. A nurse is collecting data from a client who is taking valproic acid for the treatment of a bipolar disorder. Which of the following findings is the priority to the provider? A. Dizziness B. Weight gain C. Constipation D. Yellow sclerae D. Yellow sclerae RAT: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is yellow sclerae because of the risk for hepatotoxicity. A nurse is reinforcing teaching about food that contains tyramine with a client who has a prescription for phenelzine. Which of the following foods should the nurse instruct the client to void? A. Fried chicken B. Oranges C. Smoked sausage D. Lentils C. Smoked sausage RAT: Smoked sausages are high in tyramine. Clients who are prescribed monoamine oxidase inhibitors (MAOIs) should avoid food that contain tyramine because consuming them can cause a hypertensive crisis. A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and their own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? A. Discuss information about the dilemma with the client's provider. B. Determine the benefits and consequences of respecting the client's medical decisions. C. Reflect on the effect of ethical theories on the nurse's personal values. D. Develop a plan that balances both the nurse's values and the client's medical decisions. B. Determine the benefits and consequences of respecting the client's medical decisions. RAT: After the nurse collects the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the client's medical decisions as the next step in the ethical decision-making model. A nurse is caring for four clients who are displaying the use of defense mechanisms. Which of the following clients should the nurse identify as using maladaptive defense mechanism? A. A client who has multiple sclerosis stops taking their medication and says their diagnosis is wrong. B. An adolescent client who has difficulty with reading becomes a star athlete. C. A client admires a high school principal who separated two students who were having a fight. D. A client who has a gambling disorder volunteers in a head start program. A. A client who has multiple sclerosis stops taking their medication and says their diagnosis is wrong. RAT: Suppression is the blocking of thoughts or feelings that a client finds unacceptable. Denying the presence of an illness is a maladaptive use of a defense mechanism. A nurse is caring for a client who is scheduled for electro conclusive therapy ECT. Which of the following actions should the nurse take prior to the procedure? A. Keep the client in a side-lying position. B. Administer morphine IV. C. Prepare the client for intubation. D. Administer atropine sulfate IM. D. Administer atropine sulfate IM. RAT: In preparation for ECT, the nurse should administer atropine sulfate IM 30 min prior to the procedure. This will decrease secretions in order to prevent aspiration that can be caused by the vagal stimulation induced by ECT. A nurse is talking with a client who has borderline personality disorder. The client states they think that the other nurses avoid them, but they are afraid to share this thought with the other staff. Which of