1/13/23, 10:11 PM Mental Health blue print
A nurse in an acute mental health facility is reviewing the medication records for
a group of clients. The nurse should expect a prescription for memantine for a
client who has which of the following diagnoses?
Alzheimer's disease
Rationale:
The nurse should expect a prescription for memantine for a client who has moderate to severe
Alzheimer's disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of
manifestations and to improve cognitive function.
A nurse is collecting data from a client who takes an MAOI for the treatment of
depression. Which of the following findings is the priority for the nurse to report
to the provider?
Elevated blood pressure
Rationale:
The nurse should identify that the greatest risk to the client is an elevated blood pressure, which
increases his risk for a hypertensive crisis that can result from taking an MAOI. The nurse should apply
the safety and risk reduction priority-setting framework when collecting data from this client. This
framework assigns priority to the factor or situation posing the greatest safety risk to the client. When
there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse
should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client.
A nurse is reviewing the medications of a client who has bipolar disorder and a
new prescription for lithium. The nurse should identify that it is safe to administer
which of the following medications while the client is taking lithium?
Valproic acid
Rationale:
Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for the nurse to
administer both of these medications to the client.
A nurse is collecting data from a client who has cocaine intoxication. Which of
the following findings should the nurse expect?
Increased maternal alertness
Rationale:
The nurse should expect a client who has cocaine intoxication to have increased mental alertness due to
its stimulant properties.
A nurse is caring for a client who has schizophrenia. The nurse notices that the
client is pacing up and down the hall very rapidly and muttering in an angry
manner. Which of the following actions should the nurse take first?
Approach the client in a non threatening manner
Rationale:
about:blank 1/13
, 1/13/23, 10:11 PM Mental Health blue print
The first action the nurse should take is to approach the client calmly, in a non threatening manner, to
create a non threatening environment. The nurse should apply the least restrictive priority-setting
framework when caring for this client. This framework assigns prior to nursing interventions that are least
restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive
interventions promote client safety without using restraints. The nurse should only use physical or
chemical restraints when the safety of the client, staff, or others is at risk.
A nurse in an acute mental health facility is participating in a nursing staff
discussion about the legal aspects of involuntary admissions. Which of the
following information should the nurse include?
An involuntary admission is justified if the client is a danger to others
Rationale:
A client who is a danger to others or to himself qualifies for an involuntary admission. The inability to meet
basic needs due to the need for mental health treatment is also a justification for an involuntary
admission.
A nurse is reinforcing teaching with a client who has a new prescription for
disulfiram for the management of alcohol dependence. Which of the following
dietary choices should the nurse instruct the client to avoid?
Pure vanilla extract
Rationale:
The nurse should instruct the client to avoid alcohol and alcohol-containing substances, such as pure
vanilla extract, which taking disulfiram. The ingestion of alcohol while taking this medication causes a
disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension.
A nurse is reinforcing teaching with the family of a client who has Alzheimer's
disease about donepezil. Which of the following statements should the nurse
include?
"Donepezil can improve cognitive functioning during the earlier stages of the disease."
Rationale:
The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe
Alzheimer's disease. Although donepezil does not prevent the progression of Alzheimer's disease, it is
intended to prolong the client's ability to function in the early stages of the disease.
A nurse is reviewing the medical history of a client who has a new prescription
for electroconvulsive therapy (ECT). Which of the following findings should the
nurse identify as the priority?
Cardiac arrhythmia
Rationale:
A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that the greatest
risk for death due to ECT is related to cardiac complications.
about:blank 2/13
A nurse in an acute mental health facility is reviewing the medication records for
a group of clients. The nurse should expect a prescription for memantine for a
client who has which of the following diagnoses?
Alzheimer's disease
Rationale:
The nurse should expect a prescription for memantine for a client who has moderate to severe
Alzheimer's disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of
manifestations and to improve cognitive function.
A nurse is collecting data from a client who takes an MAOI for the treatment of
depression. Which of the following findings is the priority for the nurse to report
to the provider?
Elevated blood pressure
Rationale:
The nurse should identify that the greatest risk to the client is an elevated blood pressure, which
increases his risk for a hypertensive crisis that can result from taking an MAOI. The nurse should apply
the safety and risk reduction priority-setting framework when collecting data from this client. This
framework assigns priority to the factor or situation posing the greatest safety risk to the client. When
there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse
should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client.
A nurse is reviewing the medications of a client who has bipolar disorder and a
new prescription for lithium. The nurse should identify that it is safe to administer
which of the following medications while the client is taking lithium?
Valproic acid
Rationale:
Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for the nurse to
administer both of these medications to the client.
A nurse is collecting data from a client who has cocaine intoxication. Which of
the following findings should the nurse expect?
Increased maternal alertness
Rationale:
The nurse should expect a client who has cocaine intoxication to have increased mental alertness due to
its stimulant properties.
A nurse is caring for a client who has schizophrenia. The nurse notices that the
client is pacing up and down the hall very rapidly and muttering in an angry
manner. Which of the following actions should the nurse take first?
Approach the client in a non threatening manner
Rationale:
about:blank 1/13
, 1/13/23, 10:11 PM Mental Health blue print
The first action the nurse should take is to approach the client calmly, in a non threatening manner, to
create a non threatening environment. The nurse should apply the least restrictive priority-setting
framework when caring for this client. This framework assigns prior to nursing interventions that are least
restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive
interventions promote client safety without using restraints. The nurse should only use physical or
chemical restraints when the safety of the client, staff, or others is at risk.
A nurse in an acute mental health facility is participating in a nursing staff
discussion about the legal aspects of involuntary admissions. Which of the
following information should the nurse include?
An involuntary admission is justified if the client is a danger to others
Rationale:
A client who is a danger to others or to himself qualifies for an involuntary admission. The inability to meet
basic needs due to the need for mental health treatment is also a justification for an involuntary
admission.
A nurse is reinforcing teaching with a client who has a new prescription for
disulfiram for the management of alcohol dependence. Which of the following
dietary choices should the nurse instruct the client to avoid?
Pure vanilla extract
Rationale:
The nurse should instruct the client to avoid alcohol and alcohol-containing substances, such as pure
vanilla extract, which taking disulfiram. The ingestion of alcohol while taking this medication causes a
disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension.
A nurse is reinforcing teaching with the family of a client who has Alzheimer's
disease about donepezil. Which of the following statements should the nurse
include?
"Donepezil can improve cognitive functioning during the earlier stages of the disease."
Rationale:
The nurse should inform the family that donepezil is used to treat the manifestations of mild to severe
Alzheimer's disease. Although donepezil does not prevent the progression of Alzheimer's disease, it is
intended to prolong the client's ability to function in the early stages of the disease.
A nurse is reviewing the medical history of a client who has a new prescription
for electroconvulsive therapy (ECT). Which of the following findings should the
nurse identify as the priority?
Cardiac arrhythmia
Rationale:
A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that the greatest
risk for death due to ECT is related to cardiac complications.
about:blank 2/13
