MH EXAM 4 - ATI

A nurse is teaching about taking donepezil with a client who was recently diagnosed with early Alzheimer's disease. Which of the following instructions should the nurse include in the teaching? A. "You should chew the medication thoroughly prior to swallowing." B. "You should take this medication late in the evening." C. "You should take this medication with food." D. "If you miss taking a dose for a day, take 2 doses the following day."

B. "You should take this medication late in the evening."

A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited on the day in question. Which of the following cognitive impairments is the client demonstrating? A. Perseveration B. Confabulation C. Apraxia D. Agnosia

B. Confabulation

Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted. B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.

B. Imagination is used to fill in memory gaps.

Which factor would precipitate a client's use of confabulation? A. Ideas of grandeur B. Need for attention C. Marked memory loss D. Difficulty in accepting the diagnosis

C. Marked memory loss

A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? A. Flat affect B. Refusal to accept help from others C. Report of intense guilt D. Denial of the sexual assault

C. Report of intense guilt

An older adult seems to make up stories to fill in for memory lapses. Which behavior is the client displaying? A. Lying B. Denying C. Fantasizing D. Confabulating

D. Confabulating

A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

b. Survivor

The nurse is counseling an extremely distressed female victim immediately after a sexual assault. What should be the nurse's most important initial intervention? a. Collect a serum specimen for pregnancy testing. b. Ask the client to provide a sample of pubic hair for the evidence kit. c. Teach the client about the risk for sexually transmitted infections. d. Reassure the victim that the sexual assault was not her fault.

d. Reassure the victim that the sexual assault was not her fault.

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following statements should the nurse include in the teaching? ✔ A. "Donepezil can improve cognitive functioning during the earlier stages of the disease." B. "Donepezil cures the disease process if started at the first recognition of dementia." C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease." D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."

A. "Donepezil can improve cognitive functioning during the earlier stages of the disease."

A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory? A. "In what year did you graduate from high school?" B. "What is your favorite childhood memory?" C. "What did you have for supper yesterday?" D. "What is today's date?"

A. "In what year did you graduate from high school?"

A nurse in an emergency department is teaching newly licensed nurses about planning interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis

A. Determine if the client is experiencing thoughts of self-harm

A nurse is caring for a client who is a sexual assault survivor. The client says, "I feel so humiliated. I don't want anyone to know what happened to me." Which of the following responses should the nurse make? A. "You will be just fine. You'll see." B. "Are you saying that you are fearful of what others will think?" C. "This is a normal feeling after what happened to you." D. "The best thing for you to do is to put this event out of your mind and think positive thoughts."

B. "Are you saying that you are fearful of what others will think?"

A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take? A. Ask the client what she believes she did to deserve being physically abused B. Avoid documenting subjective verbatim statements from the client regarding injuries C. Talk to the client about making a safety plan D. Explain the cycle of violence to the client

C. Talk to the client about making a safety plan

The nurse is teaching the family caregivers how to communicate with a patient who has dementia. What communication strategy can improve orientation of the patient?

Call the person by name every time you see him or her

During morning care, an AP asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response?

Confabulation

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of this medication every 72 hr C. Offer the client a PRN NSAID while taking this medication D. Administer the medication at bedtime

D. Administer the medication at bedtime

An 18-month-old client is scheduled for a minor surgical procedure. The client has numerous large bruises of different stages over the back and buttocks. The mother states that the child must have fallen down while playing alone but cannot provide specific information. How should the nurse evaluate this situation? a. Possible child abuse b. Indications of tissue fragility c. Normal findings in an 18-month-old d. Immature parenting

Possible child abuse

A pregnant female comes to the emergency department with bruises on her arms and abdomen after a fight with her boyfriend. What is most important for the nurse to address when teaching this client?

Risks of pregnancy complications caused by abuse

A nurse is teaching a class on domestic violence to high school students. Which statement by a student would indicate to the nurse that further teaching is needed? a. "If you are educated and have money, abuse does not happen." b. "Abusers are often excessively jealous and possessive." c. "The abuser will often apologize and promise to stop." d. "Violence often begins in a dating relationship."

a. "If you are educated and have money, abuse does not happen."

A 15-year-old female student visits the school nurse's office asking about date rape and pregnancy. She confides that her boyfriend forced her to have sex against her will. What would be the most appropriate initial intervention by the nurse? a. Administer a pregnancy test. b. Identify the student's immediate concerns and feelings. c. Teach safe sex practices. d. Teach methods of birth control.

b. Identify the student's immediate concerns and feelings.

A five-year-old child has been removed from the home because of sexual abuse by the stepfather. What information should the nurse include when teaching the child's mother about possible consequences the child might experience? a. Because the abuser was someone well known by the child, the situation will be less traumatic for the child. b. The child is at current risk for developing depression and will remain so in the future. c. Since the child was removed from the home at an early age, no long-term consequences are expected. d. Once an adult, the child should be counseled not to have children, as the child will become an abuser.

b. The child is at current risk for developing depression and will remain so in the future.

A five-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse's assessment reveals bruises in the child's genital and rectal areas. The mother reports that she had left the little girl with her boyfriend the night before. Which action should be the nurse's first priority with this client? a. Assess the child for other health problems. b. Obtain a urine sample to confirm a UTI. c. Report suspected sexual abuse to protective services. d. Teach the mother about symptoms of UTI.

c. Report suspected sexual abuse to protective services.

An adult survivor of child abuse states, "Why couldn't I make him stop the abuse? If I were a stronger person, I might have been able to make him stop. Maybe it was my fault he abused me." Based on this data, which would be the most appropriate priority nursing concern? a. Social isolation b. Anxiety c. Inability of family to cope d. Chronic low self-esteem

d. Chronic low self-esteem