ATI Mental health Assessment

a nurse is assisting with planning care for a client who is in the manic phase of bipolar disorder. which of the following actions is the priority for the nurse to include in the plan

offer frequent high calorie fluids throughout the day

a nurse is caring for a client who has early dementia and is prone to wandering at night. which of the following strategies should the nurse use to help keep the client safe

place the clients mattress on the floor

a nurse is collecting data from a client who has depression. which of the following findings should the nurse expect

poor concentration

a nurse is collecting data from a client who received diazepam 10mg PO 1 hr ago. which of the following findings should the nurse identify as an indication that the client is experiencing benzodiazepine toxicity?

respiratory rate 10/min

a nurse is collecting data from a client who has generalized anxiety disorder (GAD). which of the following findings should the nurse expect

restlessness

a nurse is contributing to the plan of care for a client who has anorexia nervosa and is 60% of their ideal body weight (IBW). which of the following interventions should the nurse include

set structured mealtimes for the client

a nurse is caring for a newly admitted client who has a diagnosis of schizoid personality disorder. the nurse should expect the client to exhibit which of the following behaviors

social isolation

a nurse is caring for a client who is experiencing a severe panic attack. which of the following actions should the nurse take during the panic attack

stay with the client. instruct the client to take slow, deep breaths. set physical limits.

a nurse is caring for a client on a mental health unit and receives a call from the client's sibling requesting information regarding the client's condition. the client has not listed anyone on the release of information form. which of the following actions should the nurse take?

tell the caller that information cannot be released regarding their request

a nurse is caring for a client who recently experienced a traumatic event. the nurse should identify that which of the following is an example of the client using repression as a defense mechanism

the client reports not being able to remember anything about the event

a nurse is caring for a client who is in the manic phase of bipolar disorder. which of the following findings should the nurse report to the provider immediately

the client sleeps about 2 hr per night

a nurse is admitting a client to a mental health unit. the nurse should inform the client that they have which of the following rights

the right to retract previously provided consent. the right to receive individualized care. the right to refuse psychotropic medications. the right to the least restrictive environment

a nurse is caring for a client following a modified radical mastectomy. which of the following client statements is an indication of effective coping

I am planning to attend a support group after I leave the hospital

a nurse is reinforcing teaching with a newly licensed nurse about the guidelines for use of mechanical restraints. which of the following statements made by the newly licensed nurse indicates an understanding of the teaching.

I should apply mechanical restraints on a client who is attempting to harm themselves prior to obtaining a prescription

a nurse is reinforcing discharge instructions with a client who has bipolar disorder and is taking lithium. which of the following statements by the client indicates an understanding of the teaching

I will have the level of medication in my blood checked regularly

a nurse is reinforcing discharge teaching with a client who has alcohol use disorder. which of the following statements by the client indicates an understanding of relapse prevention

I'm learning which situations I have difficulty handling

a nurse is reinforcing teaching with a client who is preparing for a conditional release following involuntary admission. which of the following statements by the client indicates an understanding of the teaching.

If I don't follow the instructions in my conditional release, I might be readmitted

a nurse is assisting with the care of a client immediately following electroconvulsive therapy (ECT), which of the following findings should the nurse document as an unexpected response to the procedure

Irregular heart rhythm

a nurse is preparing to collect data from a client who has delirium. which of the following findings should the nurse expect

disorientation that fluctuates

a nurse is collecting data from a client who has schizophrenia. when asked questions, the client keeps repeating what the nurse says rather than providing answers. the nurse should document this finding as which of the following alterations of speech

echolalia

a nurse is caring for a client who has schizophrenia and reports anxiety due to hearing voices. which of the following actions should the nurse take

encourage the client to listen to music using headphones

a nurse is caring for a client who is experiencing acute alcohol withdrawal. the client becomes agitated and the nurse administers lorazepam 2 mg IM. which of the following actions should the nurses take

ensure a staff member remains with the client continuously

a nurse is caring for a client who has insomnia disorder. which of the following actions should the nurse take

establish a routine that signals the end of the day

a nurse is caring for a client who frequently displays manipulative behavior. which of the following actions should the nurse take

establish consequences for the client's actions

a nurse is establishing a therapeutic relationship with a client who has generalized anxiety disorder. which of the following actions should the nurse take first

explain confidentiality guidelines to the client

a nurse is planning an in-service about eating disorders for a group of staff nurses. which of the following conditions should the nurse include as a risk factor for anorexia nervosa?

a diagnosis of obsessive-complusive disorder

a nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. which of the following manifestations should the nurse instruct the client to report to the provider as an adverse effect of this medication

abdominal pain

A nurse is reinforcing teaching with a client who has schizophrenia and new prescription for fluphenazine. which of the following adverse effects should the nurse include in the teaching

akathisia, hypotension, drowsiness

a nurse is reinforcing teaching with a client who has a prescription for a monoamine oxidase inhibitor (MAOI). which of the following lunch choices by the client indicates an understanding of the teaching

an egg salad with a sliced tomato and a yeast roll

a nurse is collecting data from a 5 year old child who is brought to the emergency department by a parent who states that the child feel out of a tree. the child is guarding their right arm. for which of the following findings should the nurse suspect physical maltreatment

an x-ray of the right arm indicates a spiral fracture

a nurse is caring for a client who is obese and states, " I need to lose weight to be attractive again." which of the following actions should the nurse take first to promote positive self-esteem.

ask the client how they feel about their weight and appearance

a nurse is caring for a client who has Parkinson's disease. the client states, " Everything is looking pretty grim for me." Which of the following is priority action for the nurse to take

ask the client if they have a specific plan of suicide

a nurse is caring for a client who is experiencing a paranoid delusion. the client is becoming increasingly anxious. which of the following interventions should the nurse take

ask the client to describe the delusion

a nurse in a long term care facility is caring for a client who has dementia and cannot verbalize their wants and needs. the client refuses to drink liquids on meal trays. which of the following actions by the nurse demonstrates advocacy

ask the client's family what their favorite beverages are

a nurse is contributing to the plan of care for a client who has moderate alzheimer's disease and is neglecting personal hygiene. which of the following interventions should the nurse include in the plan

assign an assistive personnel (AP) to help the client with personal hygiene

a nurse is caring for a client who is admitted for alcohol use disorder. the client states, " I have not had anything to drink for 24 hours" which of the following is the priority nursing interventions

check the client's vital signs

a nurse is collecting data from a client who is taking paroxetine. which of the following adverse effects should the nurse identify as the priority

confusion

a nurse is reinforcing teaching regarding family therapy with the parents of a client who has anorexia nervosa. the parents tell the nurse, " we don't understand why we have to have family therapy we are not sick". which of the following responses should the nurse provide

family therapy explores how the family dynamic impact your son

a nurse is caring for a client who says. " I quit taking my lithium. I did not like the way I felt on that drug." which of the following responses should the nurse make

how do you feel when you take the medication

a nurse is caring for a group of clients. which of the following actions by the nurse demonstrates the ethical concept of veracity

informing a client about the adverse effects of a prescribed treatment

a nurse is contributing to the plan of care for a client who is experiencing acute alcohol withdrawal. which of the following interventions should the nurse recommend

initiate seizure precautions for the client

a nurse is caring for a client who takes haloperidol. the nurse should expect that the provider will prescribe which of the following laboratory tests

liver function

a nurse is interviewing an adolescent client who reports that they were sexually assaulted. which of the following actions should the nurse take?

move the client to a private examination room to perform the interview.

a nurse is collecting data from a client who is seeking help regarding their sexuality. which of the following statements by the client should the nurse identify as a finding of hypoactive sexual desire disorder

my libido is not as strong as it use to be

a nurse is reinforcing discharge teaching with the family of a client who has mild dementia. the family plans to care for the client in their home. which of the following instructions should the nurse include?

use signs to identify different rooms in the home

a home health nurse is reinforcing teaching with the family members of a client who has alzheimers disease and is experiencing sleep disturbance. which of the following instructions should the nurse include

wake the client at the same time each morning

a nurse is caring for a client who has schizophrenia. the client is refusing to participate in the current group activity. which of the following statements the nurse make

you do not have to participate right now if you don't feel comfortable

a nurse is discussing confidentiality with a client who was just admitted to an acute mental health unit. which of the following client statements indicates an understanding of the teaching

you have to report it if I threaten to hurt anyone

a nurse is reinforcing teaching with the adult child of a client who is scheduled to have electroconvulsive therapy (ECT), which of the following statements should the nurse make

your father might experience short-term memory loss after the procedure