ATI RN Mental Health Online Practice 2019 B with NGN

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? A. "It appears as though you would like to open the door." B. "You will feel more comfortable after you've been here for a while." C. "It is okay to not want to be here." D. "You really shouldn't be pushing on the door."

A. "It appears as though you would like to open the door." This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

A nurse at a provder's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? A. Use a screening tool to evaluate the client for depression B. Ask the provider to decrease the dosage of the client's blood pressure medication C. Instruct the client to decrease intake of vitamin B12 D. Suggest the client go for a brisk walk 20 min just before bedtime

A. Use a screening tool to evaluate the client for depression Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping.

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A. A school-age child who has bruises on the knee B. An older adult client who is bedbound and has a stage IV pressure ulcer C. An adolescent who has a vaginal candida infection D. A young adult who is pregnant and has a sprained ankle

B. An older adult client who is bedbound and has a stage IV pressure ulcer A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting

A nurse is assessing a client who had major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A. Rapid improvement in affect within 30 to 60 min after taking the medication B. Greater risk of attempting suicide as affect and energy improve C. Onset of frequent, loose stools D. Development of physiologic dependence on the medication

B. Greater risk of attempting suicide as affect and energy improve The nurse shoud identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment.

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use the same plan of care and interventions for each client who has depression." B. "Each nurse will develop a separate plan of care for each client who has depression." C. "I will update the plan of care as a client's manifestations of depression change." D. "An assisstive personnel can use the plan of care for client teaching."

C. "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change.

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make? A. "Why do you think you deserve this punishment?" B. "Don't worry about being punished by God." C. "Let's talk about what is upsetting you." D. "You shouldn't say things that will upset you so much."

C. "Let's talk about what is upsetting you." The nruse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who was hit for injuries.

C. Call for a team of staff members to help with the situation The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A. An adolescent family member who questions parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household

C. Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home? A. Community mental health center B. Mental health day program C. Partial hospitalization program D. Assertive community treatment

D. Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A. Lansoprazole B. Naproxen C. Magnesium hydroxide D. Phenylephrine

D. Phenyleprine Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension