RN Mental Health Online Practice 2023 A with NGN (Already Passed!)
A nurse is caring for a client in an outpatient psychiatric clinic who has been applying
selegiline 12 mg transdermal patch once daily. Tuesday - MDD. Outpatient group therapy with SW and f/u with nurse. VS
T 98.6
b/p 114/78
HR 84
RR 16
Thursday - irritable, diaphoresis, HA, "I have a really bad feeling, my heart is pounding."
T 100.8
b/p 178/98
HR 128
RR 24 - ANSWER The patient is at risk for developing HYPERTENSIVE CRISIS due to CONSUMING FOODS HIGH IN TYRAMINE
A nurse on a mental health unit is caring for a client who has schizophrenia. dx 2 yrs ago with psychosis
Takes chlorpromazine and loxapine with minimal improvement. Student at CC and works retail
VS 0800
b/p 112/66
HR 88
RR 16
T 99.9
o2 98%
VS 1200
b/a 104/60
HR 106
RR 20
T 100.9
o2 97%
WBC 5,100
RBC 5.0
hbg 15 hct 46%
platelets 186
ANC 600 - ANSWER After reviewing the client's medical record, the nurse should notify the provider of which of the following findings?
- elevated Temp
- hypoactive bowel sounds
- decreased ANC level
- myalgia
- increased HR
*adverse effects of clozapine
A nurse is caring for a client who has PTSD and new rx for sertraline
Day 1 0830
T 97.9
HR 92
RR 22
b/p 120/70
Na+ 138
K+ 3.6
Glucose 88mg
NAD
PWD
Axox4
5 hrs of sleep 6 c of caffeine Day 3 1000
T 101.7
HR 98
RR 24
b/p 140/86
Day 4
Na+ 132
K+ 4.0
Glucose 77
Clammy and moist
restless
HA and Nausea
64oz of water - ANSWER A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication?
- Temperature
- Sodium level - Diaphoresis
- Insomnia
- Headache
- Blood pressure
A nurse is caring for a client who has impaired cognition.
Day 1, 0800
tx UTI 8 months ago
T 98.4
HR 92
RR 26
b/p 132/80
assist with self care
easily startled
Day 3, 0830
Fell. Bruise L knee
T 99.1
HR 106
RR 32
b/p 144/86
wandered
restless
increased anxiety - ANSWER Plan of care: Anticipated, nonessential, or contraindicated
When addressing the client, approach from the front - ANTICIPATED
Use a vest restraint to keep the client in a medical recliner
- CONTRAINDICATED
Ensure the bed is kept at a working height for the nurse
- CONTRAINDICATED
Provide the client with high-calorie protein drinks hourly
- NONESSENTIAL
Give directions to the client slowly and in a moderate tone of voice
- ANTICIPATED
Decrease sensory stimulation
- ANTICIPATED
Keep the lights off in the client's bedroom at bathroom at night
- CONTRAINDICATED
A nurse is caring for a client in an outpatient psychiatric clinic who has been applying
selegiline 12 mg transdermal patch once daily. Tuesday - MDD. Outpatient group therapy with SW and f/u with nurse. VS
T 98.6
b/p 114/78
HR 84
RR 16
Thursday - irritable, diaphoresis, HA, "I have a really bad feeling, my heart is pounding."
T 100.8
b/p 178/98
HR 128
RR 24 - ANSWER The patient is at risk for developing HYPERTENSIVE CRISIS due to CONSUMING FOODS HIGH IN TYRAMINE
A nurse on a mental health unit is caring for a client who has schizophrenia. dx 2 yrs ago with psychosis
Takes chlorpromazine and loxapine with minimal improvement. Student at CC and works retail
VS 0800
b/p 112/66
HR 88
RR 16
T 99.9
o2 98%
VS 1200
b/a 104/60
HR 106
RR 20
T 100.9
o2 97%
WBC 5,100
RBC 5.0
hbg 15 hct 46%
platelets 186
ANC 600 - ANSWER After reviewing the client's medical record, the nurse should notify the provider of which of the following findings?
- elevated Temp
- hypoactive bowel sounds
- decreased ANC level
- myalgia
- increased HR
*adverse effects of clozapine
A nurse is caring for a client who has PTSD and new rx for sertraline
Day 1 0830
T 97.9
HR 92
RR 22
b/p 120/70
Na+ 138
K+ 3.6
Glucose 88mg
NAD
PWD
Axox4
5 hrs of sleep 6 c of caffeine Day 3 1000
T 101.7
HR 98
RR 24
b/p 140/86
Day 4
Na+ 132
K+ 4.0
Glucose 77
Clammy and moist
restless
HA and Nausea
64oz of water - ANSWER A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication?
- Temperature
- Sodium level - Diaphoresis
- Insomnia
- Headache
- Blood pressure
A nurse is caring for a client who has impaired cognition.
Day 1, 0800
tx UTI 8 months ago
T 98.4
HR 92
RR 26
b/p 132/80
assist with self care
easily startled
Day 3, 0830
Fell. Bruise L knee
T 99.1
HR 106
RR 32
b/p 144/86
wandered
restless
increased anxiety - ANSWER Plan of care: Anticipated, nonessential, or contraindicated
When addressing the client, approach from the front - ANTICIPATED
Use a vest restraint to keep the client in a medical recliner
- CONTRAINDICATED
Ensure the bed is kept at a working height for the nurse
- CONTRAINDICATED
Provide the client with high-calorie protein drinks hourly
- NONESSENTIAL
Give directions to the client slowly and in a moderate tone of voice
- ANTICIPATED
Decrease sensory stimulation
- ANTICIPATED
Keep the lights off in the client's bedroom at bathroom at night
- CONTRAINDICATED
