Mental Health ATI Final

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?

A. encourage the client to participate in group therapy

B. instruct the client to avoid napping during the day

C. offer the client high-calorie finger foods frequently

D. decrease the client's daily fiber intake

C. offer the client high-calorie finger foods frequently

Rat; high-calorie finger foods can be eating while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration

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"

C. "Suddenly I have enough energy to do anything I want"

D. "Thank you for always taking such good care of me"

B. "It is easier to talk about my feelings now"

Rat; When client express their feelings, this indicates a positive treatment outcome

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?

A. complete written documentation every 60 min.

B. request a PRN prescription for restraints after the client has been reintegrated to the unit.

C. renew prescription for restraints every 48 hr.

D. ensure a staff member checks on the client every 15 min.

D. ensure a staff member checks on the client every 15 min

Rat; the nurse should assess the client's needs for hydration and elimination, and monitor the circulation in the extremities every 15 min

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?

A. Somnolence

B. Blood pressure 154/96 mm Hg

C. Pinpoint pupils

D. Blood glucose 210 mg/dL

B. Blood pressure 154/96 mm Hg

Rat; clients who experience alcohol withdrawal is expected to have hypertension, tachycardia, and a fever greater than 100.9 F

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

A. emotional lability

B. self-sacrificing

C. suspicious of others

D. grandiosity

A. emotional lability

Rat; emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder.

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

A.) panic

B.) moderate

C.) severe

D.) mild

D.) mild

Rat; this is when the client will be able to concentrate and process information. all other levels have a decreased chance of concentration

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 guardians is the priority for the nurse to reports to the provider?

A.) reduced appetite

B.) fatigue

C.) dark urine

D.) sweating

C.) dark urine

Rat; the greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death. Therefore, this is the priority finding

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?

A. stealing money from family to cover credit card charges

B. exercises twice a week

C. anxious if left alone

D. same job for 12 years

E. well-nourished female

F. hyper sexualization

G. well-groomed

H. married multiple times

I. incidences of self-injury

A, C, F, H, I

Rat;

Stealing money from family to

cover credit card charges is correct.-

The nurse should identify that stealing money is an impulsive behavior, which is a

manifestation of borderline personality disorder.

Anxious if left alone is correct.-

The nurse should identify that the client's anxiety about being left alone is due to fear of

separation, which is a manifestation of borderline personality disorder.

Hypersexualization is correct.-

The nurse should identify that hypersexualization is an impulsive, self-damaging

behavior, which is a manifestation of borderline personality disorder.

Married multiple times is correct.-

The nurse should identify that unstable romantic relationships are a manifestation of

borderline personality disorder.

Incidences of self-injury is correct.-

The nurse should identify that self-injury is a manifestation of borderline personality

disorder. Self-destructive behaviors, such as cutting, are common with this disorder.

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

A.) reluctance to discard worthless objects

B.) avoidance of interpersonal relationships

C.) intense efforts to avoid abandonment

D.) inability to maintain employment

C. intense efforts to avoid abandonment

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

A.) buprenorphine

B.) disulfiram

C.) bupropion

D.) chlordiazepoxide

D. Chlordiazepoxide

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

A.) WBC count 6,000/mm (5,000 to 10,000)

B.) Platelets 250,000/mm (150,000 to 400,000)

C.) Sodium 140 mEq/L (136 to 145)

D.) Blood glucose 256 mg/dL (74 to 106)

D. Blood glucose 256 mg/dL

A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

- Cardiac assessment

- Client's recent loss

- Neurological assessment

- Smoking history

- Client's recent consumption of alcohol

- Genitourinary assessment

- Respiratory assessment

- Blood alcohol level

- Gastrointestinal assessment

- Cardiac assessment

- Neurological assessment

- Client's recent consumption of alcohol

- Blood alcohol level

A nurse performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?

A.) CAGE Questionnaire

B.) Denver II Developmental Screening Test

C.) Geriatric Depression

D.) Pain Assessment in Advanced Dementia Scale

C. Geriatric Depression Scale

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?

A.) nonmaleficence

B.) veracity

C.) justice

D.) autonomy

A. nonmaleficence

Rat; it is the nurse's responsibility to do no harm to clients.

A nurse is caring for a newly admitted client. For each potential assessment finding, click to specify if the finding is consistent with the positive or negative symptoms of schizophrenia.

- Delusions of grandeur

- Clang associations

- Catatonia

- Alogia

- Hallucinations/paranoia

- Disorganized/bizarre thoughts, behaviors, or speech

- Withdrawal from social activities

- Lack of goal-directed behavior

- Social Discomfort

- Inability to enjoy activities

Positive symptoms

- Delusions of grandeur

- Clang associations

- Catatonia

- Alogia

- Hallucinations/

paranoia

- Disorganized/bizarre thoughts, behaviors, or speech

Negative symptoms

- Withdrawal from social activities

- Lack of goal-directed behavior

- Social Discomfort

- Inability to enjoy activities

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?

A.) Response prevention

B.) Guided imagery

C.) Aversion therapy

D.) Light therapy

B.) Guided imagery

Rat; guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have PTSD

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?

A.) Provide teaching about the use of positive coping mechanisms

B.) Establish screening programs to identify at-risk clients

C.) Refer survivors of intimate partner abuse to a legal advocacy program

D.) Organize rehabilitation therapy for clients who have experienced intimate partner abuse

B.) Establish screening programs to identify at-risk clients.

Rat; This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take necessary steps to address individual client needs.

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 that the client reports taking should alert the nurse to a potential adverse reactions?

A.) Lansoprazole

B.) Naproxen

C.) Magnesium oxide

D.) Phenylephrine

D.) Phenylephrine

Rat; Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other OTC medications for sinus congestion, colds, or allergies due to thier actions on the sympathetic nervous system, which can result in severe hypertension.

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 interventions should the nurse include in the plan?

A.) Document the client's behavior every 8 hours

B.) Limit the client's fluid intake to 50 mL/hour

C.) Renew the prescription for the client every 4 hours

D.) Toilet the client every 4 hours

C.) Renew the prescription for the client every 4 hours

Rat; the nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hours, for a maximum of 24 hours.

A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?

A.) Vitamin deficiency

B.) Diaphoresis

C.) Tremors

D.) Illusions

D.) Illusions

Rat;