ATI Mental Health Practice A PDF

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ATI Mental Health Practice A mental health...

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Mental Health Practice A A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? a. A client refuses electroconvulsive therapy after signing the consent form. b. A client who was voluntarily admitted left the unit against medical advice. c. A client was administered one-half of the prescribed dose of medication. d. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed. A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? a. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners. b. A client who has depression reports having a lack of interest in assisting their partner in the care of their children. c. A client who has borderline personality disorder threatened to harm their roommate. d. An adolescent client who has anorexia nervosa has a BMI of 17. 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? a. the client will take prescribed medications as scheduled b. the client will express feelings of frustration c. the client will refrain from self-mutilation d. the client will participate in group therapy A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? a. respite care b. partial hospitalization c. adult day care program d. geropsychiatric unit 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? a. Move the client to a room near the nurses' station. b. Limit visitors until the client is oriented to the environment c. Tell the client that their partner is deceased. d. Talk with the client about activities they enjoyed with their partner. 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? a. clang association b. word salad c. neologism d. echolalia A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? a. delusions b. neologisms c. anhedonia d. echopraxia 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? a. Obtain the weight of a client who has bipolar disorder and is experiencing mania. b. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. c. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome.

d. Change the dressings of a client who has borderline personality disorder and superficial selfinflicted wounds. A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? a. feelings of remorse b. extended periods of depression c. deficits in intellectual functioning d. aggression toward animals 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? a. advise the client to take frequent sips of water b. instruct the client to avoid driving during initial therapy c. consult a dietician for a calorie-controlled diet plan d. recommend that the client exercise regularly A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? a. do not administer the lorazepam b. request a prescription for IV lorazepam c. request that another nurse attempt to administer the lorazepam d. place the lorazepam in the client’s food 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? a. the client is exhibiting echolalia b. the client reports command hallucinations c. the client reports loss of motivation d. the client is exhibiting blunted affect A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? a. emotional liability b. self-sacrificing c. suspicious of others d. grandiosity 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 this condition? a. The client needs excessive external input to make everyday decisions. b. The client demonstrates a dedication to their job that excludes time for leisure activities. c. The client adheres to a rigid set of rules. d. The client has difficulty starting new relationships unless they feel accepted. 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? a. increased confusion b. sleep disturbances c. cluttered environment d. inappropriate dress 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? a. behave in a friendly manner toward the client b. set realistic limits on the client’s behavior c. show respect for the client’s need for isolation d. act as a role model for assertiveness

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? a. gather supplies for endotracheal intubation b. administer a beta blocker intravenously c. position the client in a low-Fowler’s position d. place a cooling blanket over the client 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? a. Have the client participate in a morning aerobics group. b. Encourage frequent rest periods throughout the day. c. Provide a distraction such as television at night. d. Offer the client hot chocolate at bedtime. A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? a. A client who has a fasting blood glucose level of 80 mg/dL b. A client who has a sodium level of 128 mEq/L c. A client who has a BUN of 18 mg/dL d. A client who has a potassium level of 3.6 mEq/L A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? a. diarrhea b. heavy menstrual bleeding c. tachycardia d. orthostatic hypotension 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? a. "If you do my homework for me, I won't bother you for the rest of the day." b. "Mom is always upset." c. "It's not the children's fault. It's mine." d. "It's your fault that we're having problems as a family." 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? a. "Information regarding clients should remain confidential until after their death." b. "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." c. "As long as client identity is disguised, their health information can be shared between professionals on the internet." d. "In the event a client threatens harm to others, medications can be administered without consent." A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? a. Call the family member to the side to inquire if they have questions or concerns about the treatment plan. b. Advise the family member that this treatment plan has been developed specifically for the client to follow. c. Ask the family member if they have any thoughts or questions about the treatment plan. d. Document that the family member does not support the medication treatment plan. 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? a. schedule the client for group therapy sessions b. maintain consistent rules

c. provide frequent high-calorie snacks d. avoid the use of value judgements 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? a. "I wish I had been nicer and more generous with my wife before she died." b. "I told my wife to go to the doctor, but she wouldn't listen to me." c. "I think about my wife all the time when I go on outings with my family." d. "I feel so empty without my wife that it's hard to get up every morning." 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? a. sore throat b. photophobia c. hand tremors d. constipation 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? a. "You might notice an increase in saliva while taking this medication." b. "You might experience difficulties with sexual functioning while taking this medication." c. "You should expect an improvement in symptoms of depression in 3 to 4 days." d. "You may notice a temporary ringing in the ears when starting this medication." 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? a. Tell the client that the voices do not really exist. b. Touch the client to help reduce feelings of anxiety. c. Instruct the client to go to a quiet room when the voices start talking. d. Ask the client what the voices are saying. A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? a. Encourage the client to drink 125 mL of fluid each hour while awake. b. Allow the client to eat independently in their room. c. Weigh the client twice weekly. d. Measure the client's vital signs once each day. 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? a. ask the client to identify the bomb in the room b. initiate disaster protocols per facility policies and procedures c. assess the client for evidence of a perceptual disturbance d. convince the client that there is no bomb in their room 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? a. shuffling gait b. hypotension c. decreased WBC count d. blurred vision 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? a. the client is interested in what the nurse is saying b. the client is attempting to manipulate the nurse

c. the client is physically attracted to the nurse d. the client needs to feel accepted by the nurse 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? a. The client's chart indicates a 1.36-kg (3-lb) weight gain in 1 month. b. The client reports an inability to breathe easily. c. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL. d. The client reports having recently started smoking cigarettes. 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? a. total body fat 8.7% b. potassium 3.6 mEq/L c. temperature 36.1 C (96.9 F) d. heart rate 54/min 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? a. confront the staff member b. encourage the client to report the incident c. document the incident in the client’s health record d. report the occurrence to the charge nurse 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? a. "I'm relieved now that my financial affairs are in order." b. "It is easier to talk about my feelings now." c. "Suddenly I have enough energy to do anything I want." d. "Thank you for always taking such good care of me." A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include? a. Taking the oral medication buprenorphine to prevent alcohol use b. Attending a relapse prevention group several times each week c. Beginning a methadone treatment program at a local center d. Living with their parent, who has promised to keep them away from alcohol A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and a temperature of 39.9° C (103.8° F). Which of the following actions should the nurse take first? a. administer phentolamine 5 mg IV to the client b. apply a hypothermic blanket to the client c. determine the client’s prescribed medication regime d. initiate IV access for the client 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? a. male gender b. hyperthyroidism c. substance use disorder d. being married A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? a. "I should eat a regular diet with normal amounts of salt and fluids." b. "I should discontinue the lithium when I begin to feel better." c. "I need to be careful to avoid becoming addicted to the lithium." d. "I can skip a dose of medication if my stomach is upset."

A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? a. Ensure a family member can be present during treatment. b, Increase fluid intake for 24 hr before the treatment starts. c. Change position slowly when the treatment is complete. d. Avoid looking directly at the light during treatment. 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? a. decrease distraction during meal times b. Provide positive feedback when the child completes a task. c. Clearly identify consequences for unacceptable behavior. d. Remove unnecessary equipment from the child's surroundings. A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? a. Arrange one-to-one observation of the client. b. Encourage interaction with the client's peers. c. Administer medication for depressive disorder. d. Encourage the client to attend a support group. A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? a. "Succinylcholine will enhance the therapeutic effects of this treatment." b. "Succinylcholine is given to reduce muscle movements during therapy." c. "Succinylcholine will decrease the anxiety level that you might experience with this treatment." d. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure." 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? a. Promote the use of music to compete with the client's auditory hallucinations. b. Inform the client that the auditory hallucinations are not real. c. Avoid asking the client if they are experiencing auditory hallucinations d. Instruct the client on the use of voice recognition regarding the auditory hallucinations. A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? a. Raise the pitch of the voice when speaking to the client. b. Begin the interview by explaining the plan of care. c. Interview the client in a private setting. d. Ask the client to complete a detailed questionnaire. A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? a. The client recently lost a grandparent in a motor vehicle crash. b. The client's town was hit by a tornado. c. The client's youngest child is leaving for college. d. The client is ambivalent about their upcoming retirement. A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? a. st. john’s wort b. saw palmetto c. echinacea d. ginkgo

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? a. "I put in extra hours at work so I won't think about drinking." b. "I know that wine is good for my heart, so that's why I drink some each evening." c. "I make up for my drinking by taking my partner on nice vacations." d. "I am able to go to work every day, so I don't have a problem." A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? a. polyphagia b. hypertension c. decreased temperature d. depressed mood 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? a. offering self b. use of silence c. attention to body language d. reflection of feeling...