ati assessment b mental health
a nurse is assessing a client who is experiencing opioid withdrawal. which of the following manifestations should the nurse report?
- sedation - rhinorrhea** - bradycardia - hypothermia
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?
- "it appears as though you would like to open the door"**** - "you will feel more comfortable after youve been here a while" -"it is okay to not want to be here" -"you really shouldnt be pushing on the door"
a nurse in an ED is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. which of the following statements by the parents acknowledges the clients diagnosis
- she works so hard at ballet, will she still be able to perform - she wont let me take the trash from her room, im concerned about what she has in there** - she told me she was tired so i did chores for her today - she is happier with her appearance now that she's lost some weight
a nurse is as assessing a client for risk factors for development of depression. the nurse should identify that which of the following factors places the client at an increased risk for depression
-client is married - client recently received a promo at work - client has COPD** - client is male
a nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. which of the following interventions should the nurse include in the plan
-document the clients behavior q8h - limit the clients fluid intake to 50 ml/hr - renew the prescription for the client q4h** - toilet client q4h
a nurse is reviewing lab results for a client who has schizophrenia and is taking clozapine. which of the following values should the nurse identify as a contraindication for recieving clozapine
- WBC count 2500** - hgb 11.5 - platelets 150000 - RBC 3.5 mil
a nurse is caring for four clients in an ED. the nurse should identify that which of the following clients can give informed consent
- a 17 year old client who lives with friends - a 50 year old client who has a BAC of 80 - a 35 year old client who has MDD*** - a 65 year old client who just received a dose of morphine
a nurse on an acute mental health care facility is receiving change of shift report for four clients. which of the following should the nurse assess first
- a client who does not recognize familiar people - a client who can not verbalize their needs - a client who is awake and disoriented at night - a client who is experiencing delusions of persecution **
a nurse is receiving change of shift report for four clients. which of the following should the nurse plan to see first?
- a client who has avoidant personality disorder and refuses to attend group therapy - a client who has bipolar disorder and reports being kidnapped by aliens overnight - a client who is taking bupropion and reports having insomnia the last 2 nights - a client who is taking clozapine and reports a sore throat and chills **
a nurse in the ED is caring for four clients. which of the following clients is the nurse required to report as a potential victim of abuse
- a school aged child who has bruises on knees - an older adult client who is bed bound and has a stage 4 pressure ulcer*** - an adolescent who has a vaginal candida infection - a young adult who is pregnant with a sprained ankle
a nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. which of the following information about relapse should the nurse incude
- additional acute episodes of depression are unlikely following inpatient care - early identification of changes, such as decreased social involvement, is important** - medication compliance will prevent further need for inpatient hospitalization - it is helpful to regularly reinforce to the client that things will get better
a nurse is planning care for a client who is to undergo ECT. which of the following actions should the nurse include in the plan?
- administer phenytoin 30 min prior to the procedure - instruct the client to expect a headache following the procedure - place the client in four point restraints prior to procedure - monitor the clients cardiac rhythm during procedure ***
a nurse on a mental health unit is caring for a group of clients. which of the following actions by the nurse is an example of the ethical principles of justice?
- allowing a client to choose which unit activities to attend - attempting alternative therapies instead of restraints for a client who is combative - providing client with accurate info about their prognosis - spending adequate time with a client who is verbally abusive**
a nurse is assessing a client who has bulimia nervosa. the nurse should expect which of the following findings?
- amenorrhea - lanugo - cold extremities - tooth erosion**
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
- an adolescent family member who questions parental authority - a family with three generations in the same household - older children who are responsible for their younger siblings** - two adults and their children from prior relationships in the same household
a nurse in a mental health clinic is caring for a client who has PTSD after returning from military deployment. which of the following is a priority action for the nurse to take
- assist client to identify personal areas of strenght - encourage the client to talk about experiences during the deployment - stay with the client when flashbacks occur** - teach the client stress management techniques
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
- call the provider obtain an immediate prescription for restraint - prepare to administer benzodiazepine IM - call for a team of staff members to help with the situation** - check the client who was hit for injuries
a nurse is preparing to participate in a interdisciplinary conference for a client who has bipolar disorder. which of the following behaviors is the priority for the nurse to report to treatment team?
- calling family members - spending time alne - giving away possessions*** - excessive crying
a charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. which of the following statements should the charge nurse take
- clients cant refuse to take medication if they are admitted involuntarily - you can notify a clients family if they are admitted involuntarily - clients who are admitted involuntarily maintain the right to give informed consent for procedures** - you can remove a clients privileges if they are admitted involuntarily and refuse to attend therapy sessions
a school nurse is assessing a school age child who experienced the traumatic loss of a parent 8 mos ago. which of the following findings should the nurse identify as an indication that the child is experiencing PTSD
- clinging behaviors directed toward a teacher - increased time spent sleeping - intense focus on school work - lack of interest in an upcoming holiday **
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
- community mental health center - mental health day program - partial hospitalization program - assertive community treatment**
a nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. which of the following should the nurse include in the teaching?
- complete documentation about the clients status every hour while they are in restraints - maintain the client in restraints for a minimum of 4 hr - apply restraints when other means of managing the clients behavior have failed** - request that the provider assess the client within 8 hr of the application of restraints
a nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. which of the following actions is the first component of a safety plan?
- develop a code word that means "time to go" - Identify signs of escalation of violence** - have a predetermined place to go in the event of violence - keep a hidden packed bag of necessities
a nurse in a mental health clinic is planning care for four clients. which of the following tasks should the nurse delegate to an assistive personnel
- discuss outpatient resources with a client who has PTSD - create a plan of care for a client who is experiencing alcohol withdrawal - explain sleep hygiene to a client who has insomnia - stay with a client who has anorexia nervosa for an hour after meals**
a nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. which of the following therapeutic nursing interventions is the priority?
- encourage expression of feelings - support the child's attendance at an assertiveness training group - assist the child to perform relaxation breathing - reduce environmental stimuli **
a nurse is planning care for a client who has bipolar disorder and is experiencing mania. which of the following interventions should the nurse include in the plan of care
- encourage the client to participate in group therapy - instruct the client to avoid napping during the day - offer the client high calorie finger foods frequently*** - decrease the clients daily fiber intake
a nurse is talking with a group of parents who have recently experienced the death of a child. which of the following actions should the nurse take?
- encourage the parents to avoid discussing the death with their other children to protect their feelings - recommend each parent grieve in private to avoid hindering each other's healing - suggest forming a weekly support group for parents who have experienced the death of a child*** - advise the parents to begin counseling if they are still grieving in a few months
a nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. which of the following manifestation of this disorder should the nurse include in the teaching
- fear of abandonment - motor and verbal tics - hostile behavior - language delay**
a nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. which of the following statements by the client indicates acceptance of her illness
- i am going to order a wheelchair for when im unable to walk ** - i am going to stop paying my bills since i wont be around much longer - i wish you would go take care of somebody who actually needs you - i am sure im going to be able to continue to care for myself without help
a nurse is providing teaching the partner of a client who is in rehab for alcohol use disorder. the nurse should identify that which of the following indicates understanding of the teaching
- i will avoid social events until my partner has completed treatment - it is important for me to focus my attention on my partners addiction - i will not take charge of my partners work responsbilities** - i want my partner to promise to change addictive behavior
a nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. which of the following statements by the client indicates an understanding of the teaching
- i will spend extra time at work to keep from feeling depressed - i will talk about my feelings to a close friend** - i will be able to learn how to prevent my partner's attacks - i will use meditation instead of taking my antidepressants
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
- i will use the same plan of care an interventions for every client with depression -each nurse will develop a separate plan of care for each client who has depression - i will update the plan of care as the clients manifestations of depression change*** - an assistive personnel can use the plan of care for client teaching
a nurse in a mental health facility is caring for a client who has schizophrenia. which of the following findings places the client at the greatest risk for self directed injury or injuring clients?
- inability to communicate with others - feelings of absence of self worth - lack of motivation to perform daily tasks - command hallucinations**
a nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. which of the following interventions should the nurse include in the plan
- include a liquid supplement with meals - identify the clients trigger foods ** - allow the client at least 1 hour for each meal - weigh client at bedtime each day
a nurse is caring for a client who has alcoholic cardiomyopathy. which of the following laboratory findings should the nurse expect?
- increased creatine phosphokinase** - increased LDL - decreased fasting blood glucose - decreased aspartate aminotransferase
a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. to establish a trusting nurse client relationship, which of the following actions should the nurse take first
- inform the client that this admission is confidential*** - introduce the client to other clients in the day room - assist the client in facilitating behavioral changes - determine coping strategies that the client has used in the past
a nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. which of the following OTC meds that the client reports taking should alert the nurse to a potential adverse reaction
- lansoprazole - naproxen - magnesium hyrdoxide - phenylephrine**
a client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has a severe depression. the client who has depression reports to the nurse "my roommate never sleeps and keeps me up too". which of the following actions should the nurse take?
- move the client who has bipolar disorder to a private room** - administer sleep medication to the client who has bipolar disorder - move the client who has severe depression to a private room - administer sleep medication to the client who has severe depression
a nurse is planning care for a client who has repeated physical threats toward others on the unit. although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. which of the following ethical principles should the nurse apply in this situation
- nonmaleficence** - veracity - justice - autonomy
a nurse is teaching the partner of a client who has bipolar disorder how to ID manifestations of acute mania. which of the following findings should the client's partner report to the HCP
- obsessive attention to detail - inability to sleep** - reports of fatigue - isolation from others
select all that apply a nurse is preparing to discharge to home an older adult client who attempted suicide. the client lives alone and has difficulty performing ADLs. which of the following referrals should the nurse initiate?
- occupational therapy** - meal delivery services** - speech language pathologist - physical therapy** - home health services **
a nurse is caring for an older adult client who is experiencing delirium. which of the following interventions should the nurse include in the child's plan of care
- offer the client various choices for meal selection - assign different nursing personnel for each shfit - permit the client to perform daily rituals to decrease anxiety** - maintain an environment that has low lighting
a nurse is caring for a client who is experiencing a panic attack. which of the following actions should the nurse take?
- orient the client to person, place and time - assist the client with deep breathing exercises*** - calm the client by using therapeutic touch - have the client sit alone in a quiet room
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?
- panic -moderate - severe - mild***
a nurse is planning prevention strategies for partner violence in the community. which of the following strategies should the nurse include as a method of secondary prevention?
- provide teaching about the use of positive - establish screening programs to identify at-risk clients**** - refer survivors of intimate partner abuse to a legal advocacy program - organize rehab therapy for clients who have experienced intimate partner abuse
a nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. which of the following outcomes should the nurse expect
- rapid improvement in affect within 30-60 min after taking the med - greater risk of attempting suicide as affect and energy improve*** - onset of frequent, loose stools - development of physiologic dependence on the medication
a nurse in a community health center is teaching families of clients who have ptsd about expected clinical manifestations. which of the following should the nurse include
- repeatedly talks about the traumatic incident - sleeps excessively - experiences feelings of isolation** - uses repetitive speech
a nurse in a community health care center is working with a group of clients who have PTSD. which of the following interventions should the nurse include to reduce anxiety among the group members?
- response prevention - guided imagery ** - aversion therapy - light therapy
a nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. which of the following assessment findings supports the nurse's suspicion of delirium
- slow onset - aphasia - confabulation - easily distracted**
a nurse on a med sure unit is assessing a client who sustained injuries 12 hr ago following a MVA. the clients admission blood alcohol level was 325. which of the following indicate to the nurse that the client is experiencing alcohol withdrawal
- somnolence - BP 154/96** - pinpoint pupils - blood glucose 210
a nurse is facilitating a community meeting for acute care clients. one client is constantly talking and using the majority of the group's time. which of the following interventions should the nurse implement?
- tell the client to talk less or risk being removed from the meeting - ask group members to discuss their feelings about this client's monopolizing behavior*** - end the group meeting and take the client aside to discuss the disruptive behavior - focus on other group members and ignore the client who is doing all the talking
a nurse is discussing a 12 step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. which of the following info should the nurse include in the teaching
- the program will help the client accept responsibility for the disorder - the client should obtain a sponsor before discharge for an increased chance of recovery** - the client will need to identify individuals who have contributed to the disorder - the program will need a prescription from the clients provider prior to attendance
a nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. which of the following statements made by the guardian indicates an understanding of the child's illness
- this disease will increase our child's risk for high BP - it is important for our child to have regular dental checkups ** - we need to weigh our child daily for several weeks, then once per week - bleeding during our child's periods will increase because of this disease
a nurse at a providers office is interviewing an older adult client. which of the following actions should the nurse plan to take?
- use a screening tool to evaluate the client for depression** - ask the provider to decrease the dosage of the clients BP meds - instruct the client to decrease intake of vitamin B12 - suggest the client go for a brisk walk 20 min just before bed time
a nurse is caring for a child who is taking methylphenidate. the nurse should monitor the child for which of the following findings as an adverse effect?
- weight gain - tinnitus - tachycardia*** - increased salivation
a nurse is caring for an older adult client wh begins to cry and states "i knew god would punish me and i deserve his horrible sickness". which of the following responses should the nurse make
- why do you think you deserve this punishment - dont worry about being punished by god - lets talk about what is upsetting you *** - you shouldnt say things that will upset you this much
a nurse is caring for a client who gave birth to a stillborn baby. which of the following statements should the nurse make
- you probably want to hold your baby - ill stay with you in case you want to talk** - i know how you must be feeling - it hurts now but things will be better soon
a nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. the client states "im so fat i cant even stand to look at myself". which of the following therapeutic responses demonstrates the nurses use of summarizing
- youve discussed several concerns about your weight. lets go back and talk about your belief that you're fat - you're saying that you think that you are fat and are using laxatives because you're afraid of gaining weight** - you dont want to look at yourself because you think you are fat - you and i can work together to overcome your fears of gaining weight
a nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. the nurse should administer benztropine to relieve which of the following adverse effects
-blurred vision - orthostatic hypotension - dry mouth - acute dystonia **
