ATI Mental Health Practice B

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Suggested forming a weekly support group for parents who have experienced the death of a child

A nurse is teaching a newly licensed nurse about nursing care plans for clients you have depressive disorders. Shut the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a client's manifestations of depression change."

Providing teaching to the client. Which of the following statements should the nurse include in the teaching?

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

A nurse observes the client on a mental health unit pushing on a 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 an older client who begins to cry and states, "I knew God will 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"

For each potentials providers prescription click to specify if the potential prescription is anticipated, nonessential, or contraindicated

-Apply restraints - contraindicated -Urinalysis was culture and sensitivity - anticipated -insert indwelling urinary catheter - contraindicated -melatonin - anticipated -MRI of the head - nonessential - IV fluids - anticipated

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated

-Haloperidol 2mg Im - anticipated -Holden next dose of buspirone - contraindicated -request change of diet to mechanical soft - nonessential -request prescription for digoxin 1 mg IV bolus STAT - contraindicated -call me approach client and state, "you seem agitated. Let's sit quietly and talk about it" _ anticipated

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?

1.5

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?

35-year-old client who has major depressive disorder

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

A client who is experiencing delusions of persecution

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 stage four pressure ulcers

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment

A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours ago following a motor vehicle crash. The clients admission blood alcohol level was 325. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96 mm Hg

Nurse on a metal health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?

Call for a team of staff members to help with the situation

A charge nurse on a mental health unit is discussing clients rights with a newly licensed nurse. Which of the following statements should the charge nurse make?

Clients who are admitted involuntarily maintain the right to give informed consent for procedures

Which of the following findings should the nurse report to the provider immediately

Cognitive awareness Blood pressure Sleep/wake cycle I&O Temperature

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings place as the client at the greatest risk for self directed injury or injuring others

Command hallucinations

A nurse is performing a cognitive assessment to distinguish delirium from dementia and a client whose family reports episodes of confusion. Which of the following assessment finding supports the nurses suspicion of delirium?

Easily distracted

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establishment programs to identify at risk clients

A nurse is assisting a client who has major depressive disorder and has been receiving amitriptyline for one week. Which of the following outcomes should the nurse expect

Greater risk of attempting suicide as affect an energy improve

A nurse in a community health center is working with a group of clients your post traumatic stress disorder. Which of the following intervention should the nurse include to reduce anxiety among the group members?

Guided imagery

Nurses evaluating the client after two weeks. Which of the following findings indicate an important in the clients condition

Heart rate BMI Potassium Skin temperature Sodium Bowel movement BUN

Select the six findings found in the clients medical record that are manifestations of the client's diagnosed personality disorder

Hyper sexualization Physical altercations Married multiple times Stealing money from family to cover credit card charges Anxious if left alone Incidences of self injury

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 clients partner report to the provider

Inability to sleep

A nurse is performing an admission assessment on a client who notices that the client appears withdrawn and fearful. To establish a trusting nurse client relationship, which of the following action should the nurse take first?

Inform the client of this admission is confidential

The nurse should first ____________ followed by _____________.

Initiate IV fluids; administering acetaminophen

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

It is important for a child to have regular dental check ups

The nurses are in for the client. Which of the following actions should the nurse take?

Maintain continuous observation of the client while in restraints Conduct debriefing with a client and other stuff

A nurse is planning care for a client who is generalized anxiety disorder. Which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Mild

Nurse is planning care for a client who has made reported physical threats towards others on the unit. Although the client does not want to leave the unit, the nurse request the provider to transfer the client to unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse supply in the situation?

Nonmaleficence

A nurse is preparing to discharged to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate?

Occupational therapy Meal delivery services Physical therapy Home health services

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

A nurse is assessing a family dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of 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 what the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

A nurse is caring for the client, who is this equation and under mechanical restraint. For each potential assessment findings, click to specify if the finding indicates the clients condition has improved, not changed, declined.

Play attempts to bite nursing staff and offered water - declined Client follows instructions of the nurse - improved Client is silent and glaring at staff - not changed Client verbalizes precipitating factors to violent outbursts - improved

The nurse is assessing a client who is this playing manifestations of delirium. Which of the following information from the clients medical record or risk factors for delirium?

Postoperative Hospital environment Client's age Fever

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 intervention should the nurse include in the plan?

Renew the prescription for the client every four hours

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?

Signs of escalation and violence

Evaluating the clients response to treatment. For each assessment finding click to specify if the finding is an improvement, no change, or decline

Sleep/wake cycle - no change Vital signs - improvement Daytime orientation - improvement Glucose level - no change I&O - improvement Pain level - improvement Ambulation - decline

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice

Spinning adequate time with a client who is verbally abusive

A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel?

Stay with a client who has anorexia nervosa for one hour after meal times

Nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as anniversary action of methylphenidate.

Tachycardia

A nurse is assessing a client for respecters for the development of depression. The nurse should identify that which of the following factors place as the client had an increased risk for depression

The client has COPD

A nurse is discussing a 12 step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increase chance of recovery

A nurse is caring for an older adult client who is experiencing delirium. The following intervention should the nurse include in the clients plan of care?

The client to perform daily rituals to decrease anxiety

a nurse other providers office is interviewing an older adult client. Which of the following actions should the nurse plan to take?

Use a screening tool to evaluate the client for depression

The client is at risk for developing _______________ as evidence by the client's

Violent behavior; increased agitation

A nurse is reviewing laboratory results for a client who has schizophrenia and it's taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine?

WBC count 2500

A client who has a recent diagnosis of bipolar disorder this place in a room with a client who has severe depression. The client who has depression reports to the nurse, "my roommate never sleeps and keeps me up, too." The following actions should the nurse take?

What is the client who has bipolar disorder to a private room

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 nurse is updating the plan of care for a client who has bolimia nervosa and is 5% above their ideal body weight. Which of the following intervention should the nurse include in the plan?

identify the client's trigger foods

A nurse is caring for a child who has conduct disorder is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is a priority?

reduce environmental stimuli

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

tooth erosion

Nurse is caring for the client. Which of the following action should the nurse take for this client?

-maintain a low stimulation environment for the client -offer the client warm milk at bedtime -search the client from the front and speak slowly

For each potential provider's prescription, click to specify if they prescribe therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder.

-systematic desensitization - obsessive compulsive disorder -validation therapy - dementia -dialectical behavior therapy - borderline personality disorder -donepezil 5 mg po - dementia -fluoxetine 20 mg Po- obsessive compulsive disorder

Nurses receiving change of shift report for four clients which of the following client should the nurse plan to see first?

A client who is taking clozapine and reported sore throat and chills

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

A nurse is providing teaching to the partner of a client who is in rehabilitation program for alcohol use disorder. The nurse should identify that way but the following statement by the client's partner indicate my understanding of the teaching?

I will not take charge of my partners work responsibilities

A nurse is teaching coping charges to 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 nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?

I'll stay with you just in case you want to talk