VATI Mental Health Assessment

A nurse is assessing a client who is taking fluphenazine and received a dose of benztropine to treat an acute dystonic reaction. Which of the following findings indicates that the benztropine is effective?

Decrease in facial muscle spasms.

A nurse is creating a plan of care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse plan to include?

Decrease the volume of the television in the dayroom.

A nurse is caring for a client who has schizophrenia and is experiencing frequent delusions. Which of the following strategies should the nurse use when caring for the client?

Identify the client's feelings underlying the delusions.

A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first?

Inform the client that this admission is confidential.

A nurse is providing teaching to a client who has bipolar disorder and has been taking lithium for 4 months. The client's serum lithium levels are within the therapeutic range. Which of the following instructions should the nurse include to promote the maintenance of the therapeutic lithium level?

Limit outdoor exercise during hot weather.

A nurse is providing morning care for a client who has Alzheimer's disease and has frequent outbursts of aggression. Which of the following actions should the nurse take?

Limit the client's choices.

A nurse is teaching a client who has alcohol use disorder about medications that can be used to treat manifestations of withdrawal. The nurse should include information about which of the following medications?

Lorazepam

A nurse in an acute care mental health facility is preparing a client for discharge. Which of the following tasks should the nurse include in the termination phase of the nurse-client relationship?

Make appropriate referrals.

A nurse is planning care for a client who is taking benztropine to reduce extrapyramidal manifestations developed secondary to taking an antipsychotic medication. For which of the following adverse effects of benztropine should the nurse monitor?

Tachycardia

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

Tachypnea

A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?

The client refuses to drink fluids.

A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?

This therapy will help me recognize changes in my blood pressure.s.

A nurse is leading a medication education group for several clients. A client who is sometimes violent becomes angry and begins yelling at others in the group. Which of the following actions should the nurse take? SATA

Move others away from the client. Offer the client a PRN dose of lorazepam. Ask the client open ended questions about the behavior.

A charge nurse is discussing elder abuse with a newly licensed nurse. Which of the following responses by the newly licensed nurse demonstrates an understanding of elder abuse?

Older adults who are dependent on a caregiver might be at an increased risk for abuse.

A nurse is counseling a client who has alcohol use disorder and has chosen to enter a treatment program. The clients states, "I need to find a program that won't interfere with my job." The nurse should identify which of the following community resources as being the least restrictive?

Outpatient treatment program.

A nurse is discussing resources with the case manager of a client who has schizophrenia and heart failure. Which of the following resources should the nurse recommend to address the client's behavioral health and medical needs?

Patient-centered medical home (PCMH)

A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan?

Provide the client with plastic eating utensils.

A charge nurse is planning an in-service for a group of newly licensed nurses about the use of restraints. Which of the following information should the nurse include?

Record the client's behavior every 15mins while in restraints.

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take?

Redirect the client attention using reality based conversation.

A nurse is assigning tasks to a licensed practical nurse and an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Remain with a client who has anorexia nervosa following a meal.

A nurse is caring for a client who has schizophrenia and is exhibiting violent behavior. After staff members place the client in restraints, which of the following actions should the nurse take?

Request that the provider see the client within 1hr.

A nurse is planning to teach a group of clients about techniques to change unwanted behaviors. Which of the following techniques is the nurse using when she acts out different scenarios and has clients respond by practicing new behaviors?

Role Playing.

A nurse is checking laboratory values for a hospitalized young adult client who has bipolar disorder and is taking lithium. Which of the following values is the priority for the nurse to report to the provider?

Serum creatinine 2.1 mg/dL

A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Sharpened perceptions.

A charge nurse is conducting an in-service for a group of newly licensed nurses about risk factors for child maltreatment. Which of the following examples should the nurse include in the teaching?

A child who was born with cleft lip and palate.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis?

A client who recently lost their home in a fire.

A nurse in an emergency department is preparing to discharge a client who has severe HTN and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?

A residential rehabilitation program..

A nurse is preparing to administer methylphenidate 30mg PO to a school age child who has ADHD. Available is methylphenidate oral solution 10mg/5mL. How many mL should the nurse administer?

15 mL

A nurse is assessing a group of clients in a community health clinic. In which of the follwoing situations should the nurse identify a requirement to report child or vulnerable adult maltreatment to an appropriate agency? SATA

A 7-year-old child has a variety of old and new bruises on his back and posterior thighs. A 2-year-old child has a spiral fracture of his arm, which the parent states happened when he fell from a swing. An 80-year-old client who has dementia and lives in a group home has bruises in the perineal area.

A charge nurse is teaching a group of newly licensed nurses about different types of therapeutic support groups. Which of the following statements should the nurse make?

A bereavement support group helps clients who are experiencing loss.

A nurse is caring for a client whose partner recently died. Which of the following actions should the nurse take?

Allow the client to experience and express grief in personally unique ways.

A nurse is discussing therapeutic communication with a group of newly licensed nurses. Which of the following phrases should the nurse use as an example of offering general leads?

And after that?

A nurse is creating a plan of care for a client who has posttraumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan?

Assign the same staff to care for the client.

A home health nurse is caring for a new client who has hoarding disorder that involves food. Which of the following actions should the nurse take first?

Assist the client with completing the Hoarding Scale Self Report.

A nurse is caring for a client who has bipolar disorder and is taking carbamazepine. The nurse should monitor the client for which of the following adverse effects?

Ataxia

A nurse is providing dietary teaching to a client who has a prescription for tranylcypromine. The nurse should instruct the client to avoid which of the following foods while taking this medication?

Avocados

A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?

Avoids self responsibility.

A nurse is discussing stress management techniques with a client who has an anxiety disorder. Which of the following information should the nurse include?

Biofeedback teaches you to control physical reactions to stress, such as your heart rate.

A nurse is planning care to assist a client with smoking cessation. Which of the following medications should the nurse expect the provider to prescribe?

Bupropion

A nurse in a mental health clinic receives a phone call from a client with mental health disorder and lives at home. The client reports they cannot afford to refill their prescription for an antipsychotic medication and requests assistance. Which members of the should the nurse notify?

Case Manager

A nurse in an emergency department is assessing an older adult client who was brought in by a family member. Member reports that the client change in behavior over the past 2 days. The nurse should identify that which of the following findings is an indication that the client has delirium? SATA

Change in LOC Decreased attention span Hallucinations

A nurse is caring for a client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?

Check the client's physical needs every 15mins while in seclusion.

A nurse is caring for a client whose partner died 3 years ago. The client has withdrawn socially and has not participated in regular activities since the funeral. The nurse should identify that the client is experiencing which of the following types of grief?

Chronic grief

A nurse in an acute mental health facility is assessing a newly admitted client who has schizophrenia. Which of the following findings should the nurse identify as the priority to assess further?

Command hallucinations

A nurse is providing discharge teaching to a family member of a client who has moderate Alzheimer's disease. Which of the following information should the nurse include?

Consider using respite care services.

A nurse in a community program for clients who experience partner violence is planning secondary prevention strategies. Which of the following interventions should the nurse plan to include?

Coordinating community resources for a hospitalized client.

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

Dental caries

A nurse is planning care for a client who is withdrawing from alcohol. Which of the following medications should the nurse plan to administer during the acute phase of alcohol withdrawal?

Diazepam

A hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatment. One of the adult children is angry w/ provider and blames the provider for their father's death. Which of the following defense mechanisms is the family using?

Displacement

A nurse is caring for a client who is experiencing a manic episode. Which of the following actions should the nurse take first?

Encourage the client to rest each hour

A nurse is caring for a client who appears extremely agitated and believes that pacing the floor a specific number of times is necessary or "something terrible" will happen. Which of the following responses should the nurse make?

It must be hard for you to have to pace the floor. Let's talk about your feelings.

A home health nurse is providing education for the family of a client who has dementia. Which of the following interventions should the nurse recommend?

Limit fluid intake after the client's evening meal.

A nurse is assessing a client whose child died 1 year ago. Which of the following findings indicates the client might be experiencing major depressive disorder rather than an expected grief response?

Loss of self-esteem due to feelings of worthlessness.

A nurse is assisting in obtaining informed consent from a client who is scheduled for Vagus nerve stimulation. Which of the following actions should the nurse take to act as a client advocate?

Ensure the client signs the form voluntarily.

A nurse is reviewing a laboratory report of a client who is taking olanzapine. Which of the following laboratory values should the nurse report to the provider?

Fasting blood glucose 140 mg/dL.

A nurse is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?

Fear of being abandoned by others.

A nurse in an outpatient mental health facility is assessing a family unit that consists of grandparents, parents, and several children. Which of the following tools should the nurse plan to use to assist in assessing this group of clients?

Genogram

A nurse is assessing a client who has schizophrenia. The nurse observes lip smacking, jaw clenching, and repeated tongue protrusions. Which of the following prescribed medications should the nurse identify as the potential cause of these findings?

Haloperidol

A nurse is caring for a client following a fire that destroyed her home and killed one of her children. The client is crying and does not make eye contact with the nurse. Which of the following questions should the nurse ask first?

Have you thought of harming yourself?

A nurse is assessing a client for a substance use disorder. The client exhibits yawning, pupillary dilation, rhinorrhea, and reports muscle cramps. The nurse should suspect that the client is withdrawing from which of the following substances?

Heroin

A nurse is preparing to administer escitalopram to a client who reports taking St. John's wort 1hr ago. Which of the following actions should the nurse take?

Hold the dose of escitalopram and consult the provider.

A nurse is caring for a client who has a depressive disorder and recently started taking a selective serotonin reuptake inhibitor. For which of the following findings should the nurse monitor to identify serotonin syndrome?

Hyperpyrexia

A nurse is caring for an adult client who was involuntarily admitted following a suicide attempt. The nurse receives a call from the client's spouse asking for a status report. Which of the following responses should the nurse make?

I cannot discuss your spouse's health information with you without his consent.

A nurse in an acute care facility is providing teaching for the adult child of an older adult client who is admitted with a UTI and delirium. The client has been living independently at home. Which of the following statements by the adult child demonstrates the teaching has been effective?

I expect that my father will no longer be confused when he is discharged.

A nurse is caring for a client who has schizophrenia and is experiencing visual hallucinations. The client states, "That man on the ceiling is ridiculing me." Which of the following responses should the nurse make?

I'm sorry but I do not see anything on the ceiling.

A nurse on a mental health unit is conducting a one-on-one session with a client who suddenly becomes silent. Which of the following responses should the nurse make?

I've noticed you have become quiets. Please share with me what you are thinking.

A charge nurse on a mental health unit is discussing legal issues with a newly licensed nurse. Which of the following statements should the charge nurse include?

If a client threatens to seriously harm someone, the provider should notify that person of the threat.

A nurse is developing a plan of care for an adolescent client who has conduct disorder. Which of the following interventions should the nurse include in the plan?

Initiate a behavioral contract with the client.

A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. The nurse should identify that which of the following outcomes is an advantage of buspirone?

It does not cause physical dependence.

A nurse is providing teaching about levels of anxiety to a group of clients who have anxiety disorders. Which of the following statements should the nurse include?

Moderate anxiety causes HA and insomnia.

A nurse in a mental health facility is caring for a client who has frequent episodes of aggressive and violent behavior. The nurse should identify which of the following findings as indications that the client is at risk for imminent violence? SATA

Uses profanity to express emotions. Clenches and unclenches the jaw. Maintains intense eye contact. Paces the floor.

A nurse in an acute care mental health facility is caring for a client who has generalized anxiety disorder and suddenly begins pacing, wringing her hands, and reporting numbness and tingling in her fingers. Which of the following actions should the nurse take?

Walk with the client while setting physical limits on her behavior.

A nurse is creating a plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?

Weigh the client daily after first voiding.

A nurse is caring for a client who expresses anger and fear about the loss of a job. Which of the following responses should the nurse make?

What are some ways you can deal with the job loss?

A nurse is performing a mental status examination of a client. Which of the following questions should the nurse ask the client to assess their cognition?

What did you have for dinner last night?

A nurse is providing information to a client who is seeking voluntary admission to a mental health facility. Which of the following information should the nurse include?

You will still need to give informed consent for treatment after admission.

A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?

You're afraid you have caused physical injury to yourself?

A nurse in an emergency department is caring for a school age child who has lacerations and bruises inflicted by mother. The client's father states, "My wife was fired today and came angry. I don't think this will ever happen again." Which of the following responses should the nurse make?

Your child will be privately interviewed about the incident.