Practice A mental health online ATI

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

emotional lability

A nurse is admitting a client who has anorexia nervosa and is at 60% of their ideal body weight. Which of the following interventions should the nurse include in the plan of care?

encourage the client to drink 125 mL of fluid each hour while awake

A nurse in a mental health facility is caring for a client who requires the use of restraints. Which of the following actions should the nurse take when caring for the client?

ensure a staff member checks on the client every 15 minutes

A nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take

ensure security personnel are available in the background to assist if the client's behavior escalates

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?

establish screening programs to identify at-risk clients

A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?

experiences feelings of isolation

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 endoctracheal preparation

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

guided imagery

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

mild

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?

monitor client's cardiac rhythm during the procedure

A client who has a recent diagnosis of bipolar disorder is placed 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." Which of the following actions should the nurse take?

move the client with bipolar disorder to a private room

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?

spending adequate time with a client who is verbally abusive

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 its hard to get up evey morning

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 ml

A nurse is caring for a client who has a personality disorder. -- For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client?`

Administer haloperidol (anticipated), hold next dose of buspirone(contraindicated), request change of diet to mechanical soft (nonessential), request prescription for digoxin (contraindicated)

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is expecting alcohol withdrawal?

BP 154/96

A nurse is caring for a patient who has a personality disorder. -- The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined.

Client attempts to bite nursing staff when offered water (improved) client follows instructions of the nurse (improved), client is silent and glaring at staff (no change), client verbalizes precipitating factors to violent outbursts (improved)

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of 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 manifestation s of depression change

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

WBC 2500 clozapine can cause neutropenia

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

a client was administered one-half of the prescribed dose

A nurse is caring for a group of clients. Which of the following findings is he nurse required to report?

a client who has borderline personality disorder threatend to harm their roomate

A nurse on an acute mental health facility is receiving a change-of-shift reports for four clients. Which of the following clients should the nurse.

a client who is experiencing delusions of persecution

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?

easily distracted

36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years.

administer haloperidol (anticipated), hold next dose of buspirone (contraindicated), request change of diet to mechanical soft (nonessential), request Rx for digoxin (contraindicated), calmly approach client (anticipated)

A nurse is assessing a client who has schizophrenia. Which of the following findings should hte nurse document as a negative symptom of this disorder?

anhedonia

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 mental 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 nurse is caring for a group of clients. Which of the following findings should the nurse report?

client who takes lamotrigine and has developed a rash

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider.

dark urine

A nurse is planning discharge teaching with a new 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 environment, is important

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

hypertension

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 wont bother you anymore

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

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?

inform the client that this admission is confidential

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?

it is easier to talk about my feelings now

A 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

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 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?

lets talk about whats upsetting you

A nurse is planning care for a client who has made repeated physical threats toward 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

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

offer the client high-calorie finger foods frequently

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

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

promote the use of music to compete with auditory hallucinations

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

reduce environmental stimuli

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 clients behaviors

A nurse is caring for a client who has a personality disorder. -- Select the 6 findings in the client's medical record that are manifestations of the client's diagnosis personality disorder?

stealing money from family to cover credit card charges, anxious if left alone, hypersexualization, married multiple times, incidences of self-injury, physical altercations

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?

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

A nurse is caring for a client who has a personality disorder. -- For each potential provider's prescription, click to specify if the prescribed therapy is expected with obsessive-compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than one disease process?

systemic desensitization (obsessive compulsive disorder), validation therapy (dementia), Dialectical behavior therapy (borderline personality disorder), donepezil (dementia), fluoxetine (OCD)

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?

tachycardia

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

the client has COPD

During a client's initial interview in a mental health inpatient setting, a 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

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with the condition?

the client needs excessive extrernal input to make everyday decisions

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 increased chance of recovery