ATI Mental Health Practice B

a nurse is caring for a client who is experiencing opioid withdrawal. which of the following medications should the nurse expect to administer?

naltrexone

a nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and their own personal values. after collecting data and identifying the problem, which of the following actions should the nurse take next?

determine the benefits and consequences of respecting the client's medical decisions

a nurse is assisting with the admission of a client to an acute mental health facility. which of the following activities should the nurse plan for the working phase of the therapeutic nurse-client relationship?

evaluate the client's progress toward meeting their goals

a nurse is caring for a client who is undergoing behavioral therapy for posttraumatic stress disorder (PTSD). the nurse should identify that which of the following findings indicates an improvement in the client's condition?

the client reports about techniques they use to promote sleep

a nurse is contributing to the plan of care for a client who has antisocial personality disorder. which of the following short-term goals should the nurse recommend be included in the plan?

the client will discuss feelings that cause hostility

a nurse is collecting data from a client who has agoraphobia. the nurse should identify that which of the following situations will increase the client's anxiety?

traveling in an airplane

a nurse is collecting data from a client who has major depressive disorder (MDD) and is taking phenelzine. which of the following findings should the nurse identify as an adverse effect of this medication?

weight gain

a nurse is collecting data from a client who is taking valproic acid for the treatment of bipolar disorder. which of the following findings is the priority to report to the provider?

yellow sclerae

a nurse is caring for a client who was admitted with major depressive disorder (MDD) and states that they do not want to attend group therapy. which of the following responses should the nurse make?

"What are your feelings about going to group therapy?"

a nurse is collecting data from a client whose home was destroyed by a fire. which of the following responses should the nurse make first?

"Are you experiencing feelings of hopelessness?"

a nurse is reinforcing teaching with the parent of an adolescent who has amphetamine use disorder. the nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?

"Dilated pupils are a sign that my child is using amphetamines."

a nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. which of the following statements should the nurse make?

"Have you considered participating in a sport to help control your aggression?"

a nurse is assisting in the morning hygiene care of a client who is cognitively impaired. which of the following statements should the nurse make?

"Let me help you get your toothbrush."

a nurse is preparing to administer lithium 600 mg PO to a client who has bipolar disorder. available is lithium 150 mg capsules. how many capsules should the nurse administer? (round the answer to the nearest whole number. use a leading zero if it applies. do not use a trailing zero.)

4 capsule(s)

a nurse is caring for a client who has borderline personality disorder. for each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Administer haloperidol 2 mg IM - anticipated Hold next dose of buspirone - contraindicated Request change of diet to mechanical soft - nonessential Request prescription for Digoxin 1 mg IV bolus stat - contraindicated Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it." - anticipated

a nurse is collecting date from an older adult client who is postoperative following right knee arthroplasty. for each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Apply restraints - contraindicated Urinalysis with culture and sensitivity - anticipated Melatonin -anticipated Magnetic resonance imaging (MRI) of the head - nonessential IV fluids - anticipated

a nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). which of the following actions should the nurse take prior to the procedure?

administer atropine sulfate IM

the nurse is caring for the client who has been placed in mechanical restraints and seclusion. for each potential finding, click to specify if the finding indicated the client's condition has improved, not changed, or has declined.

Client attempts to bite nursing staff when offered water - declined Client follows nurse's instructions - improved Client is silent and glaring at staff - not changed Client verbalizes precipitating factors that lead to violent outburst - improved

a nurse is collecting data from an older adult who is postoperative following right knee arthroplasty. which of the following findings should the nurse report to the provider immediately? select the 5 findings that require immediate follow-up.

Cognitive awareness Blood pressure Sleep/wake cycle I&O Temperature

a nurse is reinforcing teaching with the caregiver of a client who has histrionic personality disorder. which of the following manifestations should the nurse tell the caregiver to expect?

attention-seeking behavior

a nurse is collecting data from an older adult client who is postoperative following right knee arthroplasty. a nurse is gathering data on a client who is displaying manifestations of delirium. which of the following information from the client's medical record is a risk factor for delirium? select all that apply.

Hospital environment Older adult Postoperative Fever

the nurse is caring for the client who has been placed in mechanical restraints and seclusion. the nurse is caring for the client who has been placed in mechanical restraints and seclusion. which of the following actions should the nurse take? select all that apply.

Maintain continuous observation of the client while in restraints Conduct debriefing with the client and other staff

a nurse is caring for a client who is experiencing delirium. a nurse is caring for an older adult who is postoperative and is experiencing delirium. which of the following actions should the nurse take? select all that apply.

Offer the client warm milk at bedtime Maintain a low stimulation environment for the client Approach the client from the front and speak slowly

a nurse is reviewing the laboratory values of a client who has anorexia nervosa. which of the following results should the nurse expect?

Potassium 3 mEq/L

a nurse is reviewing a client's medical record. the nurse is evaluating the client's response to treatments. for each client finding, click to specify if the finding indicates an improvement, no change, or a decline in the client's condition.

Sleep/wake cycle - no change Vital signs - improvement Daytime orientation - improvement Glucose level - no change I&O - improvement Pain level - improvement Ambulation - decline in condition

a nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. which of the following laboratory values should the nurse report to the provider?

Sodium 132 mEq/L

a nurse is caring for a client who has borderline personality disorder. select the 6 findings found in the client's medical record that are indications of an exacerbation of a personality disorder.

Steals money from parents to cover credit card charges Anxious if left alone Hypersexualization Married multiple times Incidences of self-injury Physical altercations

a nurse is caring for a client who has borderline personality disorder. for each potential provider's prescription, click to specify if the prescribed therapy is expected for obsessive-compulsive disorder, dementia, or borderline personality disorder. each therapy can support more than 1 disease process.

Systemic desensitization - obsessive-compulsive disorder Validation therapy - dementia Dialectical behavior therapy - borderline personality disorder Donepezil 5 mg PO daily - dementia Fluoxetine 20 mg PO daily - obsessive-compulsive disorder and borderline personality disorder

a nurse is caring for a client who is experiencing delirium. complete the following sentence by using the lists of options.

The nurse should first... assist with initiating IV fluids, followed by... administering acetaminophen.

a nurse is reviewing the medical record of a client who has schizophrenia. for which of the following findings should the nurse withhold the client's medications and notify the provider? (click on the exhibit tabs for additional information about the client. there are three labs that contain separate categories of data.)

WBC count

a nurse is caring for four clients who are displaying the use of defense mechanisms. which of the following clients should the nurse identify as using a maladaptive defense mechanism?

a client who has multiple sclerosis stops taking their medication and says their diagnosis is wrong

a nurse is planning to collect data from a group of clients. the nurse should expect that which of the following clients is likely to exhibit speech pattern alterations?

a client who has schizophrenia

a nurse on a mental health unit is caring for four clients who have schizophrenia. which of the following clients should the nurse see first?

a client who is experiencing command hallucinations

a nurse is caring for a client who recently lost their child in a motor-vehicle crash. the client is expressing feelings of hopelessness. which of the following questions is the most important for the nurse to ask?

"Have you had any thoughts of harming yourself?"

a nurse is monitoring communication between a client who has alcohol use disorder and their partner. which of the following communication patterns of the client's partner should the nurse identify as being effective?

"I become very angry when you get drunk."

a nurse is caring for a client who states, "I just lost my job. This has been the worst day of my life." which of the following responses should the nurse make?

"Tell me about your day."

a nurse in a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. which of the following statements indicates an understanding of the teaching?

"The consent form should have the name of the provider who is performing the procedure on the form."

a nurse is caring for a client who has borderline personality disorder. complete the following sentence by using the lists of options.

The client is at the highest risk for developing... violent behavior as evidenced by the client's... increased agitation.

a nurse is caring for a client who has depressive disorder and declines electroconvulsive therapy (ECT) despite the provider's recommendation. which of the following ethical principles is the nurse demonstrating by supporting the client's decision?

autonomy

a nurse is participating in group therapy for clients who have major depressive disorder. which of the following topics should the nurse include in the orientation phase of group therapy?

confidentiality

a nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. which of the following actions should the nurse take to demonstrate modeling as a behavioral intervention strategy?

demonstrating performing hand hygiene at appropriate times

a nurse is collecting data from a client who is experiencing alcohol withdrawal. which of the following findings should the nurse expect?

elevated blood pressure

a nurse is collecting data from a client who has delirium. the nurse should identify which of the following conditions as a predisposing factor for delirium?

hepatic failure

a nurse is reinforcing teaching with a client who has a new prescription for phenelzine. the nurse should instruct the client that eating foods containing tyramine can cause which of the following adverse reactions with this medication?

hypertensive crisis

a nurse in an inpatient mental health unit is supervising a group of clients in the unit's dayroom. the nurse fails to respond to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. for which of the following if the nurse liable?

negligence

a nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. which of the following interventions should the nurse include in the plan?

restrict the client's sodium intake

a nurse is collecting data from a client who has a history of cocaine use. which of the following findings is an indication that the client is experiencing cocaine toxicity?

seizures

a nurse is caring for a client who has schizophrenia and a prescription for haloperidol. the nurse should identify that which of the following findings indicates a potential need for a PRN dose of benztropine?

shuffling gait

a nurse is reinforcing teaching about food that contains tyramine with a client who has a prescription for phenelzine. which of the following foods should the nurse instruct the client to avoid?

smoked sausage

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

stand in front of the client when speaking