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
a selegiline 12 mg transdermal patch once daily.
Complete the following sentence by using the lists of options.
The client is at risk for developing _______ due to ______
Dropdown 1:
-Extrapyramidal side effects
-Hypertensive crisis
-Dry mouth
Dropdown 2:
-Taking an antipsychotic medication
-Anticholinergic reaction
-Consuming foods high in tyramine - ANSWER The client 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. After reviewing the client's medical record, the nurse should notify the provider of which of the following findings?
Select the 5 unexpected findings that require notification of the provider. -Temperature -Blood pressure
-Bowel sounds
-WBC count
-ANC count
-Myalgia
-Heart rate - ANSWER When taking actions, the nurse should identify an elevated temperature, hypoactive bowel sounds, a decreased ANC level, myalgia along with an increased heart rate can be adverse effects of the medication clozapine. Therefore, the nurse should report these findings to the client's provider .
A nurse is caring for a client who has posttraumatic stress disorder and a new prescription for sertraline.
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?
Select all that apply.
-Temperate
-Heart rate
-Sodium level
-Diaphoresis -Insomnia
-Headache
-Glucose level
-Potassium level
-Blood pressure - ANSWER When taking actions, the nurse should identify that an increased temperature, decreased sodium level, diaphoresis, insomnia, headache, and elevated blood pressure can be adverse effects of the medication sertraline. Therefore, the nurse should report these findings to the provider.
A nurse is caring for a client who has impaired cognition.
A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
-When addressing the client, approach them from the front when possible.
-Use a vest restraint to keep the client in a medical recliner.
-Ensure the bed is kept at a working height for the nurse.
-Provide the client with high-calorie protein drinks hourly.
-Give directions to the client slowly and in a moderate tone of voice.
-Decrease sensory stimulation.
-Keep the lights off in the client's bedroom and bathroom at night.
-Assign the client to a room near the nurses' station. - ANSWER When addressing the client, approach them from the front when possible is anticipated. A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote aggressive behavior in the client.
Use a vest restraint to keep the client in a medical recliner is contraindicated. The client has the right to be free from the use of restraints except in the case of an emergency.
Ensure the bed is kept at a working height for the nurse is contraindicated. The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the client does fall.
Provide the client with high-calorie protein drinks hourly is nonessential. This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has mania with this type of dietary supplement.
Give directions to the client slowly and in a moderate tone of voice is anticipated. Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause the client to feel uncomfortable and can even cause feelings of anger.
Decrease sensory stimulation is anticipated. A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair client safety.
Keep the lights off in the client's bedroom and bathroom at night is contraindicated. This can increase the client's risk for falls. Keeping a light on can decrease wandering.
Assign the client to a room near the nurses' station is anticipated. This promotes client safety by allowing staff to observe the client frequently.
A nurse is caring for a newly admitted client.
For each potential assessment finding, click to specify if the finding is consistent with
positive or negative symptoms of schizophrenia. -Delusions of grandeur -Clang associations
-Catatonia -Alogia
-Withdrawal from social activities - ANSWER Delusions of grandeur, clang associations, and catatonia are potential assessment findings of positive symptoms of schizophrenia. Other positive symptoms include hallucinations, paranoia, and disorganized/bizarre thoughts, behaviors, or speech.
Alogia and withdrawal from social activities are potential assessment findings of negative symptoms of schizophrenia. Other negative symptoms include lack of goal-
directed behavior, social discomfort, and the inability to enjoy activities.
A nurse is caring for a group of clients. Which of the following findings should the nurse report?
a. A client who is taking clozapine and has a WBC count of 7,500/mm3 (5,000 to 10,000/mm3).
b. A client who is taking lamotrigine and has developed a rash.
c. A client who is taking valproate and has a platelet count of 200,000/mm3 (150,000
to 400,000/mm3). d. A client who is taking lithium and has increased thirst. - ANSWER b. A client who is taking lamotrigine and has developed a rash.
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately.
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?
a. Gather supplies for endotracheal intubation.
b. Administer a beta blocker intravenously.
c. Position the client in a low-Fowler's position.
d. Place a cooling blanket over the client. - ANSWER a. Gather supplies for endotracheal intubation.
The nurse should gather supplies for endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
a. Panic
b. Moderate
c. Severe
d. Mild - ANSWER d. Mild
A nurse is caring for a client in an outpatient psychiatric clinic who has been applying
a selegiline 12 mg transdermal patch once daily.
Complete the following sentence by using the lists of options.
The client is at risk for developing _______ due to ______
Dropdown 1:
-Extrapyramidal side effects
-Hypertensive crisis
-Dry mouth
Dropdown 2:
-Taking an antipsychotic medication
-Anticholinergic reaction
-Consuming foods high in tyramine - ANSWER The client 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. After reviewing the client's medical record, the nurse should notify the provider of which of the following findings?
Select the 5 unexpected findings that require notification of the provider. -Temperature -Blood pressure
-Bowel sounds
-WBC count
-ANC count
-Myalgia
-Heart rate - ANSWER When taking actions, the nurse should identify an elevated temperature, hypoactive bowel sounds, a decreased ANC level, myalgia along with an increased heart rate can be adverse effects of the medication clozapine. Therefore, the nurse should report these findings to the client's provider .
A nurse is caring for a client who has posttraumatic stress disorder and a new prescription for sertraline.
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?
Select all that apply.
-Temperate
-Heart rate
-Sodium level
-Diaphoresis -Insomnia
-Headache
-Glucose level
-Potassium level
-Blood pressure - ANSWER When taking actions, the nurse should identify that an increased temperature, decreased sodium level, diaphoresis, insomnia, headache, and elevated blood pressure can be adverse effects of the medication sertraline. Therefore, the nurse should report these findings to the provider.
A nurse is caring for a client who has impaired cognition.
A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
-When addressing the client, approach them from the front when possible.
-Use a vest restraint to keep the client in a medical recliner.
-Ensure the bed is kept at a working height for the nurse.
-Provide the client with high-calorie protein drinks hourly.
-Give directions to the client slowly and in a moderate tone of voice.
-Decrease sensory stimulation.
-Keep the lights off in the client's bedroom and bathroom at night.
-Assign the client to a room near the nurses' station. - ANSWER When addressing the client, approach them from the front when possible is anticipated. A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote aggressive behavior in the client.
Use a vest restraint to keep the client in a medical recliner is contraindicated. The client has the right to be free from the use of restraints except in the case of an emergency.
Ensure the bed is kept at a working height for the nurse is contraindicated. The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the client does fall.
Provide the client with high-calorie protein drinks hourly is nonessential. This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has mania with this type of dietary supplement.
Give directions to the client slowly and in a moderate tone of voice is anticipated. Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause the client to feel uncomfortable and can even cause feelings of anger.
Decrease sensory stimulation is anticipated. A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair client safety.
Keep the lights off in the client's bedroom and bathroom at night is contraindicated. This can increase the client's risk for falls. Keeping a light on can decrease wandering.
Assign the client to a room near the nurses' station is anticipated. This promotes client safety by allowing staff to observe the client frequently.
A nurse is caring for a newly admitted client.
For each potential assessment finding, click to specify if the finding is consistent with
positive or negative symptoms of schizophrenia. -Delusions of grandeur -Clang associations
-Catatonia -Alogia
-Withdrawal from social activities - ANSWER Delusions of grandeur, clang associations, and catatonia are potential assessment findings of positive symptoms of schizophrenia. Other positive symptoms include hallucinations, paranoia, and disorganized/bizarre thoughts, behaviors, or speech.
Alogia and withdrawal from social activities are potential assessment findings of negative symptoms of schizophrenia. Other negative symptoms include lack of goal-
directed behavior, social discomfort, and the inability to enjoy activities.
A nurse is caring for a group of clients. Which of the following findings should the nurse report?
a. A client who is taking clozapine and has a WBC count of 7,500/mm3 (5,000 to 10,000/mm3).
b. A client who is taking lamotrigine and has developed a rash.
c. A client who is taking valproate and has a platelet count of 200,000/mm3 (150,000
to 400,000/mm3). d. A client who is taking lithium and has increased thirst. - ANSWER b. A client who is taking lamotrigine and has developed a rash.
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect of the medication and report this finding immediately.
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?
a. Gather supplies for endotracheal intubation.
b. Administer a beta blocker intravenously.
c. Position the client in a low-Fowler's position.
d. Place a cooling blanket over the client. - ANSWER a. Gather supplies for endotracheal intubation.
The nurse should gather supplies for endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
a. Panic
b. Moderate
c. Severe
d. Mild - ANSWER d. Mild
