Mental Health ATI Practice Assessment B

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior

"If you do my homework for me, I won't bother you for the rest of the day R: this is an ex of manipulative behavior

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 nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching

"I will not take charge of my partner's work responsibilities *person needs to take care of their own repsonsibilities

A nurse is teaching coping strategies to a client who is experiencing depression related to intimate partner abuse. Which of the following statements by the client indicates an understanding of the teaching

"I will talk about my feelings with a close friend." R: discussion feelings w a support person is effective coping

A nurse is teaching the parents of a client about their daughter's diagnosis of bulimia nervosa. Which of the following statements made by the parents indicates an understanding of their daughter's illness

"It is important for our daughter to have regular dental checkups R: repeated vomiting erodes tooth enamel and predisposes the teeth to caries. likely: ortho hypotension monitor weight but not daily can exacerbate pts worry amenorrhea

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make

"It is not uncommon to feel angry toward yourself or others."

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

"Let's talk about what is upsetting you." R: nurse is acknowledging the ot concerns and is showing desire to understand what the pt is thinking and feeling

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse

"Succinylcholine is given to reduce muscle movements during therapy R: succinylocholine is a muscle paralyzing agent that will decrease muscle movement during the procedure so that injury is less likely to occur

cloazapine

-agranulocytosis fatal blood disorder -constipation -weight gain -ortho hypotension

ECT not for

1) client who has recently been diagnosed with severe depression R: ECT not appropriate as first line tx for recent diagnosis 2) client whose depression is secondary to situational difficulties R: ECT not effecrive for clients whose depression stems from situational or social problems

A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? (Select all that apply

1. Pt who is suicidal and need rapid tx R: ECT is a rapid, definitive response for suicidal pt 2. pt w bipolar d/o w rapid cycling R: works best for these pt 3. pt w mania and not responding to med therapy (ECT for clients with mania and have not responded to medication therapy)

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero

1.5

A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent a)17 yo who lives with friends b)50yo who has blood alcohol level of .08 c)35yo who has major depressive disorder d)65yo who just received a dose of morphine

35yo who has major depressive disorder (pt w major depressive d/o can make decisions unless legally incompetent) a)not 18 b)intoxicated legally cant d) opiod analgesic makes functionally incompetent due to medication effect on the CNS

A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs

A client who has severe Alzheimer's disease R: these pt are typically confused, have memory difficulties, tend to wander, and will need assistance

A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first

A client who is experiencing delusions of persecution R: greatest risk due to the pt belief that a person in power is out to harm him.

A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse a) adolescent parents b)family in which both parents respond indifferently c)family where one or both parents witnessed intimate partner violence in the home as children\ d)family in which one or both parents has dev disability

A family where one or both parents witnessed intimate partner violence in the home as children R: They are more likely to become abused themselves. all risks tho!

A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching

Administer the last dose of medication to your child 6 hours before bedtime R: A/E of dextro. is insomnia Not to give 30 min before eating (lose appetite) Expect -weight loss constipation

A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate

Aggression toward animal

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect

Hypertension R: it is a stimulant that increase BP, HR, body temp, energy levels, and metabolism, decreases appetite

A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include

Attending a relapse prevention group several times each week R: most effective relapse prevention is a 12 step program such as AA

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 R: active listening involves identifying verbal and nonverbal communication

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following

Clang association R: clang often rhymes or contains a string of words tha can have the same beginning sounds

A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement

Discuss spiritual issues in a conversational manner *do in a normal way not formal that would be with a pastor

A nurse in a provider's office is collecting a health history from the parent of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the parent is the priority for the nurse to report to the provider a)reduced appetite b)fatigue c)dark urine d)sweating

Dark urine R: greatest risk for a child is liver damage from atomoxetine, which can progress to failure and death. *** read question dont have to know what effects it has just pick the worst for priority

A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first

Discuss the importance of hair with the client R: 1st action for a nurse is to assess the pt, the experience of anticipatory grieving begins w the importance of the expected loss

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take

Do not administer the lorazepam R: pt who is involuntarily admitted have the right to refuse tx

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 include

Early identification of changes, such as decreased social involvement, is important R: decreased social involvement in a manifestation of depression, and early identification of findings can lead to early intervention

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take

Gather supplies for endotracheal intubation R: the expected finding is resp depression -NO beta blocker client already has hypotension no need to lower it more

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team

Giving away possession R: giving away possessions indicates that the pt is a greater risk for suicide. *pick which is most dangerous!

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect a) Increased creatine phosphokinase (CPK) b) increased LDL c) decreased glucose d) decreased AST

Increased creatine phosphokinase (CPK) R: it is an enzyme released when muscle tissue is damaged *really look at what they mean has nothing to do with those things

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 a) inform that admission is confidential b)introduce to other clients c)assist in behavioral change d) determine coping strategies that client has used in the past

Inform the client that her admission is confidential (best to establish relationship) all other choices are part of working phase

school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD)

Lack of interest in an upcoming holiday R: pt w PTSD will have - moods, child can also have loss or lack of interest and participation in significant activities. negative mood and diff remembering parts of trauma. also diff sleeping, diff concentrating, distressing dreams, detachment and estrangement

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching

Language delay R: typical manifestation

A nurse is planning care for a client who constantly threatens 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 R: it is the responsibility of the nurse to not harm to clients . preventing injury to others

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 Reason: Low weight, electrolyte imbalances, starvation and dehydration

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care

Permit the client to perform daily rituals to decrease anxiety R: allowing them to do so will decrease frustration and anxiety

With delirium pts

Permit the client to perform daily rituals to decrease anxiety R: allowing them to do so will decrease frustration and anxiety need -consistent caregivers -they get frustrated wuth too many decisions to make (like picking from a lot of food) -well lit area

A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse a) scheduele the client for group therapy sessions b)maintain consistent rules c)provide frequent high calorie foods d)avoid value judgement

Provide frequent high-calorie snacks R: Maslow's requirement is for adequate nutrition ***no matter what choices always pick whats most important like FOOD

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect

Rhinorrhea R: rhinorrhea and flu like manifestions such as yawning, sneezing, and abd pain -hyperthermia, tachycardia, insomnia

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client

Set realistic limits on the client's behavior R: these pt can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive.

A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data a) ESR 18mm/hr b)hgb 15 c) serum t45 d) na 125

Sodium level 125 mEq/l R: In the presence of low Na+ levels, renal excretion of Li is reduced and the pt is at risk for Li toxicity

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect

The client recently lost a grandparent in a motor vehicle crash R: unexpected events

A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication

The client reports a sore throat R: clozapine can lead to a fatal blood d/o, agranulocytosis. this is a severe drop in WBC which leaves them at risk for infection. Nurse should w/hold

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for her deceased partner. Which of the following actions should the nurse take

Talk with the client about activities she enjoyed with her partner R: talking about + experiences can help distract her from disorientation

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists in orienting the client to reality

Talk with the client about scheduled daily activities R: this can orient the pt to time and reality throughout the day

During a client's initial interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors

The client is interested in what the nurse is saying

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client

The client will refrain from self-mutilation R: greatest risk is injury to self or others

A charge nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following information should the nurse include in the teaching

The right to treatment ensures individualized care R: The Hospitalization of the Mentally Ill Act of 1964 requires that pt admitted to an inpatient mental health facility have a right to individualized tx

A charge nurse is developing an educational program about schizophrenia. Which of the following manifestations should the nurse include as a negative symptom of schizophrenia

Thought blocking R: thought block is a - symptom of schizo. It is a sudden interruption in pt thought processes usually due to internal stimuli. client may abruptly stop talking midsentance

A nurse is reviewing the medication administration record for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects

acute dystonia *benztropine is an anticholinergic agent that relieve acute dystonia which is an extra pyramidal adverse effect of chlorpromazien

veracity

being truthful with client and others

positive signs of schizophrenia

concrete thinking (think in abstract terms) echolalia (repeats others words) posturing (client assumes an unusual or illogical position or facial expression. like grimacing

neologism

consists of words that are made up by the client

Atomoxetine adverse

dark urine sweating fatigue reduced app

during mania

disorganized, chaotic, unable to focus on detail inability to sleep talk and joke incessantly highly interactive

w bipolar disorder can have

extended periods of depression

separation anxiety

fear of abandonment

Buprenorphine

for heroin overdose

Oppositional Defiant Disorder

hostile behavior

Tourette syndrome

motor and verbal tics

Signs of anorexia nervosa

orthostatic hypotension, constipation, amenorrhea (decreased body fat and poor nutrition) tachycardia

echolalia

repeats the words of another person

autonomy

respecting clients right to make independent choices

Fluoxetine

selective seratonin reuptake inhibitor can cause sexual dysfunction such as anorgasmia and impotence -dry mouth, takes 1-3 weeks to work, visual disturbances

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression

substance use disorder not male gender (female) , marriage (single), hyperthyroidism (actually hypo)

methadone

substitute for heroin use disorder

justice

treating all equally and fairlu

word salad

words are completely meaningless and disorganized

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 I'm unable to walk." R: pt is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, indicative of acceptance.

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief

"I feel so empty without my wife that it's hard to get up every morning." R: difficulty carrying on w normal activities indicates a risk for complicated grief

A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching

"Take this medication with food R: Lithium can cause GI distress -lithium need adequate sodium to decrease lithium tox need NA 1,500 mg/day -consume 2,000-3,000 ml of fluids -not addictive

A nurse in the emergency department is admitting a client who reports a headache along with heart palpitations after having a glass of wine with dinner a few hours ago. The client has a history of depression and has a blood pressure of 210/105 mm Hg. Which of the following questions should the nurse ask first

"What medications are you currently taking?" R: If the pt is taking MAOI to tx depression, they are at a greater risk for hypertensive crisis, it can also be precipitated by tyramine containing food

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching

"You may experience difficulties with sexual functioning while taking this medication R: SSRI can cause sexual dysfunction

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

An older adult client who is bedbound and has a stage IV pressure ulcer R: Stage 4 pressure ulcer in a pt who is bedbound can indicate physical neglect and warrants reporting *any kind of abuse

A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take?

Ask the client what the voices are saying R: to determine if the pt or others are at risk for injury

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take

Ask the family member if she has any thoughts or questions about the treatment plan (involves fam to communicate)

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

Identify signs of escalation of violence *greatest risk because it increases awareness of when danger is gonna come and it is time to leave

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan

Identify the client's trigger foods R: to help=t understand the thoughts and behaviors that relate to the food of the patient. and identify what makes them initiate binge

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider

Inability to sleep R: pt is extremely active and doesn't sleep, which can lead to relapse.

A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication

Urinary retention R: OD can result in anticholinergic effects and other anticholinergic effects: constipation