Question

A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?

Answer 1

Correct Answers:

Sore throat.

Rationale :

🔴 Clozapine is associated with agranulocytosis, a serious side effect that can lead to infection, often manifesting as a sore throat.

🔴 Sore throat is a critical sign of neutropenia (low white blood cell count), which can put the client at risk for infection.

🔴 Early detection and reporting of this symptom are vital to preventing complications and ensuring prompt treatment.

🔴 This condition requires immediate attention, as clozapine-induced agranulocytosis can be life-threatening if not addressed.

🔴 The nurse should promptly report this finding to the provider and potentially discontinue clozapine if necessary.

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Answer 2

Correct Answers:

Opium.

Rationale :

🔴 The client’s tachycardia and hypertension, along with the statement, "People are out to get me", suggest acute toxicity from a stimulant or opioid.

🔴 Opium (or other opioids) can lead to delirium and paranoia, as well as the tachycardia and hypertension seen in this case.

🔴 Substance-induced paranoia is often seen with stimulants or drugs like cocaine and amphetamines, but in this case, the combination of symptoms aligns with opioid toxicity.

🔴 The nurse should monitor the client for other signs of opioid overdose and be prepared to administer naloxone if indicated.

🔴 This condition requires immediate intervention to prevent further complications such as respiratory depression or cardiovascular collapse.

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Answer 3

Correct Answers:

A client who is taking clozapine and reports a sore throat.

Rationale :

🔴 The sore throat in a client taking clozapine is a priority because it may indicate agranulocytosis, a serious side effect of the medication.

🔴 Agranulocytosis puts the client at high risk for infection, making this finding urgent to address immediately.

🔴 Even though other symptoms like schizophrenia or bipolar disorder might require attention, the potential life-threatening nature of agranulocytosis demands immediate action.

🔴 The nurse should notify the provider immediately to assess the client's white blood cell count.

🔴 Prompt intervention can prevent severe complications such as infections that may worsen the client's condition.

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Answer 4

Correct Answers:

Withhold the next dose of the medication.

Rationale :

🔴 A rash in a client taking lamotrigine can be a sign of serious side effects such as Stevens-Johnson syndrome or toxic epidermal necrolysis.

🔴 These conditions are life-threatening, requiring immediate intervention to prevent severe skin damage or even organ failure.

🔴 Withholding the next dose of lamotrigine prevents further exposure and reduces the risk of worsening rash or complications.

🔴 The nurse should also notify the provider immediately for further evaluation and management of the rash.

🔴 Early intervention is critical to mitigate the risk of severe dermatologic reactions.

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Answer 5

Correct Answers:

Reacting to the nurse as though she were his mother.

Rationale :

🔴 Transference occurs when a client unconsciously projects feelings or attitudes from a significant relationship onto another person, often the nurse.

🔴 In this case, the client reacting to the nurse as though she were their mother is a clear example of transference, which often occurs in clients with personality disorders.

🔴 Transference can complicate the therapeutic relationship but is an important concept to identify and address to provide effective care.

🔴 The nurse should use professional boundaries and reflect on how this behavior may influence the nurse-client dynamic.

🔴 Understanding transference helps the nurse navigate emotional complexities within the therapeutic relationship.

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Answer 6

Correct Answers:

Auditory hallucinations.

Rationale :

🔷 Auditory hallucinations are classic positive symptoms of schizophrenia, indicating a distortion in the client’s perception of reality.

🔷 Flight of ideas is a symptom more commonly associated with mania, not schizophrenia.

🔷 Decreased motivation and impaired memory are negative symptoms of schizophrenia, which do not fall under the "positive" category.

🔷 Positive symptoms are those that reflect excessive or distorted functioning, such as hallucinations, delusions, and disorganized speech.

🔷 The nurse should monitor the client’s response to antipsychotic medication and assess the intensity of hallucinations.

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Answer 7

Correct Answers:

Join a low-impact exercise class.

Rationale :

🔶 The client’s statement reflects social isolation, and joining a low-impact exercise class is an effective way to promote social interaction and reduce isolation.

🔶 Exercise can also help alleviate depressive symptoms, improve mood, and increase energy levels, contributing to the client’s overall well-being.

🔶 An online self-help course or journaling may also be beneficial, but exercise provides an additional social component that is particularly important for the client's mental health.

🔶 This strategy aligns with best practices in managing major depressive disorder, helping the client to reconnect socially and stay physically active.

🔶 Engaging in exercise also offers long-term benefits for both physical and emotional health.

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Answer 8

Correct Answers:

"The client is just like my brother who finally overcame his habit".

Rationale :

🔷 Countertransference occurs when the nurse unconsciously projects their feelings or experiences onto the client.

🔷 The nurse’s statement, “The client is just like my brother,” reflects personal bias and an emotional connection that could interfere with objective care.

🔷 Recognizing countertransference allows the nurse to maintain professional boundaries and ensure that personal emotions do not influence care decisions.

🔷 It's important for the nurse to reflect on their feelings and address them through supervision or self-awareness.

🔷 Objectivity is essential to providing the best care, especially in clients with substance use disorders who require nonjudgmental support.

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Answer 9

Correct Answers:

Decrease the number of verbal outbursts.

Rationale :

🔹 Clients with antisocial personality disorder often engage in impulsive behaviors, such as verbal outbursts.

🔹 The goal of behavioral therapy for these clients is often to reduce impulsivity and increase appropriate coping strategies.

🔹 By focusing on decreasing verbal outbursts, the nurse is addressing a key aspect of impulse control.

🔹 This behavior can also improve the client’s ability to interact with others and participate more effectively in therapeutic settings.

🔹 Behavioral goals like this one align with the overall aim of helping the client improve their interpersonal relationships.

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Answer 10

Correct Answers:

"How have you dealt with similar situations in the past?"

Rationale :

🔴 This question helps assess the client’s past coping mechanisms and provides insight into how they might manage stress or adversity moving forward.

🔴 Exploring past coping strategies is essential for identifying strengths and areas for growth in dealing with current challenges.

🔴 It encourages the client to reflect on their ability to handle stressful situations, which is key in assessing their coping skills.

🔴 Understanding how the client has managed difficult situations previously allows the nurse to tailor interventions to support positive coping strategies.

🔴 This question promotes empowerment and self-awareness, which are crucial for the client’s recovery from depression.

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RN ATI Mental Health-2019 NGN II

No.

1 :
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?

2 :
A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.". The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?

3 :
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

4 :
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?

6 :
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

7 :
A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "l feel unmotivated and don't feel like leaving my home.". Which of the following recommendations should the nurse make to address the client's social isolation?

8 :
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

9 :
A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

10 :
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?

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RN ATI Mental Health-2019 NGN II

No.

1 : A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?

2 : A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.". The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?

3 : A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

4 : A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?

5 : A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?

6 : A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

7 : A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "l feel unmotivated and don't feel like leaving my home.". Which of the following recommendations should the nurse make to address the client's social isolation?

8 : A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

9 : A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

10 : A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?

1 :
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?

2 :
A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.". The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?

3 :
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

4 :
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?

6 :
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

7 :
A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "l feel unmotivated and don't feel like leaving my home.". Which of the following recommendations should the nurse make to address the client's social isolation?

8 :
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

9 :
A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

10 :
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?