Mental Health ATI A
echolalia
pt. repeats the words of another person
A nurse enters a client's room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, " Back off. Leave me alone." Which of the following statements should the nurse make?
" I will give you space if you calm down. Tell me what is causing you to feel so tense."
A nurse is counseling a client who seems relaxed initially, but then becomes restless and begins ringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make?
" What were we discussing when you begin to feel uncomfortable?"
A nurse at an acute mental health facility is caring for a client who has acute mania do you to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse make?
" you must be very upset about some thing to want to see your provider in the middle of the night."
A nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse assess favorite stating, "He's the best nurse ever."When that nurse calls in sick, Which of the following statements indicates that the client is using splitting as a method of coping?
"He's the worst nurse that ever taken care of me."
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
"I am able to go to work every day, so I don't have a problem."
A charge nurse is preparing an education session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?
"In the event a client threatens harm to others, medications can be administered without consent."
A nurse is evaluating the plan of care for a client who has antisocial personality disorder. What actions indicate that he is making progress with the treatment?
-Assisting another client who has depression to fill out menu -Requesting a weekend pass to go home
A nurse in the pediatric emergency department is caring for four clients. The nurse should suspect possible abuse with which of the following clients?
A 9 month old infant who reportedly nearly drowned after climbing into the tub and turning on the water
A nurse is assessing a client who experienced a sexual assault six months ago. What should the nurse report to the provider?
Report of intense guilt
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?
Anhedonia (inability to enjoy pleasurable activities)
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?
Attention to body language
A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching?
Avoid looking directly at the light during treatment.
A nurse in the emergency department is assessing a client who has heroin intoxication. What should the nurse expect?
Respiratory depression
A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect?
Confusion
A nurse on an acute care unit is providing postoperative care to an older client who develops delirium. What action should the nurse take?
request a prescription for an antianxiety medication
A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?
Remove unnecessary equipment from the child's surroundings.
A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first?
Determine the client's prescribed medication regimen.
A nurse is caring for a client has a new diagnosis of colon cancer. Shortly after the client received the diagnosis, the nurse enters the clients room and the client begins yelling, " I have received terrible care here and no one cares about me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms?
Displacement
A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the priority for the nurse to report to the provider?
Elevated blood pressure MAOI
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?
Emotional lability
A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. What finding should the nurse question the provider's prescription?
Hypotension
A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity disorder (ADHD).What should the nurse include in her teaching?
Ignore your child's attention-seeking behaviors that are not dangerous
word salad
words are completely meaningless and disorganized
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?
Orthostatic hypotension
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?
Promote the use of music to compete with the client's auditory hallucinations.
A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. What dietary choices should the nurse instruct the client to avoid?
Pure vanilla extract. avoid alcohol-containing substances, causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?
Refrains from manipulating others to earn dining room privileges
A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM?
Shuffling gait
A nurse is caring for a client has schizophrenia. The client states, " My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions?
Somatic
A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. What action should the nurse take?
Talk to the client from two arm-lengths away
A nurse is assessing a client who has Stage 4 Alzheimer's disease. What finding should she expect?
The client is able to identify the names of family members
A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy?
The client will gain increased self-esteem.
neologism
words that are made up by the pt.
A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription of lithium. The nurse should identify that it is safe to administer what medication while the client takes lithium?
Valproic acid
clang association
often rhyme and contain a strong of words that can have a similar sound
