ATI Book Mental Health Chapters 23, 29, 30, 32, 33

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 meq/L. Which of the following actions should the nurse take? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

A

A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of women's shelters. B. Encourage the client to participate in a support group for survivors of abuse. C. Implement case management to coordinate community and social services. D. Educate the client about the use of stress management techniques.

A

A nurse is discussing routine follow‑up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Serum sodium and potassium

A

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape‑trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."

A

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (SATA) A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C. "I wish my life was over." D. "I don't feel like I can ever be happy again." E. "If I kill myself then my problems will go away."

ACE

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (SATA) A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who completed suicide C. Educating high school teens about suicide prevention D. Initiating one-on-one observation for a client who has current suicidal ideation E. Teaching middle-school educators about warning indicators of suicide

ACE

A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (SATA) A. Sudden development of phobias B. Development of substance use disorder C. Increased level of anxiety during interview D. Reactivation of a prior physical disorder E. Unwillingness to discuss the sexual assault

ACE

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C. "Young adults are the typical victims of sexual assault." D. "The majority of rapists are unknown to the victims."

B

A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."

B

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as a priority? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

B

A nurse is conducting chart reviews of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

B

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect. B. Intentionally causing an older adult to fall is an example of physical violence. C. Striking an intimate partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse

B

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (SATA) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

BCDE

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (SATA) A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus

BD

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (SATA) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

BE

A nurse working in an emergency department is assessing a preschool‑age child who reports abdominal pain. When conducting a head‑to‑toe assessment, which of the following findings should alert the nurse to possible abuse? (SATA) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

BE

A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do feel that you should not have been alone on the street at night?"

C

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 3 are at greater risk for abuse" B. "Substance use disorder does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence toward the intimate partner."

D

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the priority to report to the provider? A. "My mother has diabetes that is controlled by her diet." B. "My mother recently completed a course of prednisone for acute bronchitis." C. "My mother received her flu vaccine last month." D. "My mother is currently on furosemide for her congestive heart failure."

D

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. Assign the client to a private room B. Document the client's behavior every hour C. Allow the client to keep perfume in her room D. Ensure that the client swallows medication

D

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat of suicide is attention-seeking behavior B. Interventions are ineffective for clients who really want to commit suicide C. Using the term suicide increases the client's risk for a suicide attempt D. A no-suicide contract decreases the client's risk for suicide

D

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape‑trauma syndrome? (SATA) A. Genitourinary soreness B. Difficulties with low self‑esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

DE