Mental Health ATI Practice B

A nurse is obtalning a mental nealth nistory trom an older adult clent. which of the tollowing actions should the nurse plan to take?

Interview the client in a private setting.

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.

A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event. The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

"A support group might be helpful to you during this time." "You should seek help if you have thoughts of self-harm." "It is common for people who survived a traumatic event to experience feelings of anxiety."

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 assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

"I am going to order a wheelchair for when I'm unable to walk."

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."

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 talk about my feelings with a close friend."

A charge nurse is preparing an educational 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 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."

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 in an emergency department is caring for an adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis?

"They won't let me take the trash from their room. I'm concerned about what they have in there."

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 might experience difficulties with sexual functioning while taking this medication."

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?

"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?

A 35-year-old client who has major depressive disorder

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?

Acute dystonia

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer.

For each potential assessment finding, click to specify if it is a positive or negative symptom of schizophrenia.

Alogia (Negative) Withdrawal from social activities (Negative) Clang associations (Positive) Delusions of grandeur (Positive) Absence of intonation in speech (Negative) Catatonia (Positive)

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

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?

Apply restraints when other means of managing the client's behavior have failed.

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?

Ask group members to discuss their feelings about this client's monopolizing behavior.

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

Ask the client what the voices are saying.

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

Assess the client for evidence of a perceptual disturbance.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Assist the client with deep-breathing exercises.

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 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 admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their 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

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?

Renew the prescription for the client every 4 hr.

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?

Encourage frequent rest periods throughout the day.

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 possessions

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Hand tremors

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?

Identify the client's trigger foods.

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?

Inappropriate dress

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

Increased creatine phosphokinase (CPK)

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?

Instruct the client to avoid driving during initial therapy.

For each of the client assessment findings below, click to specify if the finding is consistent with alcohol toxicity or major depressive disorder. Each finding may support more than one disease proces

Nausea and vomiting (Alcohol tox) Weight change (Major dep) Respiratory rate (Alcohol tox) Level of consciousness (LOC) (Alcohol tox) Mental status (Major dep and alcohol tox)

A nurse in the emergency department (ED) is caring for a client who has alcohol toxicity. For each of the provider's potential prescriptions, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Obtain CT scan of brain. (Nonessential) Wake the client every 30 min for neurological assessment. (Contraindicated) Obtain an Alcohol Use Disorders Identification Test (AUDIT). (Nonessential) Administer an anti-anxiety medication. (Anticipated) Initiate IV access. (Anticipated) Monitor vital signs every 30 min. (Anticipated)

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?

Older children who are responsible for their younger siblings

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse?

Provide frequent high-calorie snacks.

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa. Click to highlight the information in the client's medical record that indicate the client's condition is deteriorating. To deselect information, click on the information again.

QT prolongation Exercise regimen Hematemesis BMI

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 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 is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Report the occurrence to the charge nurse.

A nurse in the emergency department (ED) is admitting a client who was dropped off at the front door. The nurse is assessing the client. Select the 5 findings that require follow-up.

Respiratory rate BAC Temperature Level of consciousness (LOC) Nausea and vomiting

The nurse is evaluating the client after interventions for alcohol withdrawal syndrome have been implemented. Which of the following findings indicate a positive response to therapy? (Select all that apply.)

Respiratory rate Tremors Slept with minimal disruption for 8 hr Heart rate Blood pressure Temperature

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

Rhinorrhea

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 evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? (Select all that apply.)

Sodium BMI Bowel movement Skin temperature Potassium BUN Heart rate

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

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

Talk with the client about activities they enjoyed with their partner.

A nurse is caring for a client who has alcohol use disorder. Complete the following sentence by using the list of options.

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

A nurse in the emergency department (ED) is caring for a client who has alcohol toxicity. Complete the following sentence by choosing from the lists of options.

The client is at risk for developing alcohol withdrawal syndrome as evidenced by the client's mental status.

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

The client reports an inability to breathe easily.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations.

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.

A nurse on a mental health unit is admitting a client who has bipolar disorder. Complete the following sentence by using the list of options.

The first action the nurse should take is to address the client's cardiovascular injury due to the client's constant psychomotor activity.

A nurse in the emergency department (ED) is reviewing prescriptions from the provider. Complete the following sentence by using the lists of options.

The nurse should first initiate suicide precautions, followed by initiating IV access.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?

Tooth erosion

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%