PN Mental Health Online Practice 2020 Form A & B GRADED A+ WITH NGN (RATIONALE)

PN Mental Health Online Practice 2020 Form A & B GRADED A+ WITH NGN
(RATIONALE)

A nurse is collecting data from a client who has bipolar and a history of mania. Which of the
following findings should the nurse identify as an indication that the client is relapsing?
A. Weight gain (Weight loss, rather than weight gain, can indicate relapse in a client who has
a history of mania.)
B. Pressured speech
C. Ritualistic behavior (Ritualistic behavior is an indication of obsessive-compulsive
disorder, not mania.)
D. Anhedonia (Anhedonia is a negative symptom of schizophrenia. Anhedonia is defined as a
loss of interest in daily activities and the inability or lack of capacity to experience pleasure
in general. This is not an indication of relapse in a client who has a history of mania.) - B.
Pressured speech (The nurse should identify that rapid or pressured speech, provocative
behavior, and insomnia are indications of potential relapse in a client who has bipolar
disorder and a history of mania.)
History and Physical
Subjective: Client states, "My stomach hurts."; "I feel sadder and more alone every day."
Client's adult child stated to the nurse upon dropping the client off today, "I've been meaning
to tell you, I started giving my dad St. John's wort several weeks ago to improve his mood."
Objective: Episodes of speech incoherency, rapid mood swings, 3 episodes of vomiting in the
past 40 min
Moderate Alzheimer's disease.
Provider Prescriptions
Fluoxetine 20 mg PO daily
Trazodone 50 mg PO daily at bedtime
Omeprazole 20 mg PO daily
Diagnostic Results
Blood pressure 172/94 mm Hg
Temperature 38.2° C (100.8° F)
Pulse rate 110/min
Respiratory rate 24/min
A nurse is caring for a client in a day treatment program. Which of the following actions
should the nurse take? (Click on the exhibit tabs for additional information about the client.
There are three tabs that contain separate categories of data)
A. Request - A. Request transport for the client to an emergency department. (The nurse
should request transport for the client to the nearest emergency department because the
client has manifestations of serotonin syndrome. Serotonin syndrome is a life-threatening
syndrome and is caused by an over activation of the central serotonin receptors. This is
related to interactions with taking an SSRI and trazodone along with St. John's wort.
Manifestations of serotonin syndrome include hypertension, tachycardia, vomiting,
abdominal pain, and mental status changes.)
A nurse is reinforcing teaching with a client whose provider has prescribed
electroconvulsive therapy (ECT). Which of the following information should the nurse
include?
a. The client will receive continuous oxygen during the electrical stimulation intervals.
Incorrect
(The client will receive oxygen throughout the procedure. However, the oxygen will be
removed during the brief electrical stimulation intervals.)
b. A benzodiazepine will be administered prior to the procedure. Incorrect (A benzodiazepine
should not be administered because it interferes with the seizure process. A short-acting
anesthetic, such as propofol, will be administered.)
c. ECT is an option for clients after medication has been unsuccessful.
d. Confusion is expected for the first 2 days after treatment. (Clients who receive ECT can
have confusion and disorientation for several hours after treatment.) - C. ECT is an option
for clients after medication has been unsuccessful.
(Medication is the first-line of treatment for depression. ECT is prescribed when medication
has been unsuccessful.)
A nurse is assisting with discharge planning for a client who needs to attend a day treatment
center ad has limited community and financial support. Which of the following referrals
should the nurse recommend including in the client's discharge plan?
A. Social worker
B. Recreational therapist(Although recreational therapists can promote therapies, such as
art and music, to help enhance and preserve mental health, they do not usually address
issues regarding financial support and community resources.)
C. Psychologist (Although psychologists can provide individual or family therapy for clients,
they do not usually address issues regarding financial support and community resources.)
D. Pharmacist (Pharmacists prepare prescribed medications and dispense medications in
acute care and community settings. They coordinate with the provider and nurses regarding
the client's medication regime. However, they do not address iss - A. Social worker (Social
workers can assist clients with building a support structure to help promote and preserve
mental health, including contacting day treatment centers and arranging for financial and
other community resources.)
A nurse is developing countertransference toward a client during the working phase of the
nurse-client relationship. To correct the situation, which of the following actions should the
nurse take?
A. Tell the client how to change their behaviors. (This action places responsibility on the
client to correct the situation. When dealing with countertransference, it is the nurse's
responsibility to find an appropriate solution.)
B. Talk to the client about the developing feelings. (The nurse should avoid disclosing
personal feelings because these feelings can interfere with the nurse-client relationship.
When dealing with countertransference, it is the nurse's responsibility to find an appropriate
solution, not the client's.)
C. Ask to be reassigned to a different client. (In order to achieve personal and professional
growth, the nurse should work through the issue of countertransference by caring for this
client, rather - D. identify personal response to the client.
(Countertransference is an emotional response toward the client by the nurse. This
response might be related to the nurse's past unresolved feelings or relationships. These
feelings can interfere with the nurse-client therapeutic relationship. In order to correct the
situation of countertransference, the nurse must recognize personal reactions to the client
in an attempt to work through these feelings.)