VATI Mental Health Complete

Include in care plan for client after attempted suicide:

Provide client w/plastic eating utensils.

Rationale: Glass dishes/metal silverware can cause self harm.

Admission assessment for client appearing withdrawn & fearful. Priority Action:

Priority Action: Inform client admission is confidential.

Rationale: RN should first inform client about confidentiality during orientation phase to establish trust between client & nurse, & in turn decrease

client's anxiety level.

Adolescent client w/anorexia states, "Have I done any permanent damage to my body?" RN Response:

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

Rationale: Repeating main idea of what client has said, allows for clarification of any misunderstanding on part of client or nurse.

Caring for client following a fire that destroyed home & killed one of her children. Client is crying & does not make eye contact. What question should nurse ask first?

Have you thought of harming yourself?

Rationale: Greatest risk is self harm d/t loss of child & home.

THIS LAB value is Priority to report for client taking Lithium:

THIS: ⬆Creatinine 2.1 mg/dL [Range of 0.5-1.2]

Greatest risk is ⬇ kidney function, which can increase client's Lithium level;

Lithium dosage modified based on this LAB value.

Cause of ⬆Creatinine: Dehydration, Renal disorders.

Why is Lithium is contraindicated for clients w/severe renal disease, cardiac disease, or severe dehydration?

Because these conditions ⬆ Lithium Accumulation & Toxicity, or worsen its physiologic effects.

What should RN tell a client seeking voluntary admission to a mental health facility?

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

Client who seeks voluntary admission to mental health facility has same rights as clients receiving any other kind of health care. Client still needs to give informed consent for treatment & therapies, i.e electroconvulsive therapy.

Adolescent w/conduct disorder, Nursing Intervention:

Intervention: Initiate a Behavioral Contract w/client.

Rationale: Client w/conduct disorder can demonstrate aggressive behavior, disrespect of others rights, & lead to injury of others. Behavioral contract helps develop trust between client & nurse & emphasizes client's responsibility to commit to work on changes in behavior.

Hospice nurse is talking w/family of client who died. One of adult children is angry w/provider & blames provider for their father's death. What defense mechanism is family member using?

Displacement

Rationale: When using Displacement, they are transferring their feelings of anger to provider so they don't have to cope w/their own feelings of sadness/loss.

Nurse provides teaching for adult child of an older adult client admitted w/UTI & Delirium. Client has been living independently at home. What statement by adult child demonstrates teaching has been effective?

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

Client experiencing a manic episode. Priority Action:

Priority Action: Encourage client to rest each hour.

Rationale: Greatest risk is injury from exhaustion d/t manic phase.

Client is sometimes violent, angry & begins yelling, 3 Nursing Actions:

Nursing Actions

1) Move others away from client.

2) Offer client a PRN dose of Lorazepam.

3) Ask open ended questions about behavior.

Information to include on use of restraints:

Information: Record client's behavior Q15mins while in restraints.

Rationale: Complete a written record of client's behavior Q15mins in client's medical record while in restraints.

Expected Finding w/Bulimia nervosa:

Expected: Dental caries

Rationale: Have dental caries & tooth erosion d/t excessive exposure to stomach acid from frequent vomiting.

Client w/bipolar disorder & on Lithium for 4 months. Lithium levels are within therapeutic range. Instruction to promote maintenance of therapeutic Lithium level:

Instruction: Limit outdoor exercise during hot weather.

Rationale: Spending time outdoors during hot weather, especially if exercising, promoting dehydration & Na+ loss through diuresis, can increase Lithium levels. Whenever client exercises, develops diarrhea, vomits, or has any circumstance that can cause dehydration, fluids & electrolytes must be replaced promptly.

Nurse on a mental health unit is conducting a one-on-one session w/client who suddenly becomes silent. Nurse Response:

Nurse Response: I've noticed you have become quiet. Please share w/ me what you are thinking.

Rationale: Making observation about clients feelings, encourages discussion of thoughts; facilitates further communication w/nurse.

Client appears extremely agitated; believes pacing floor a specific # of times is necessary or "something terrible" will happen. Nursing Response:

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

Rationale: Making observations & offering a general lead, allows clients to notice their behavior & discuss feelings w/nurse. Client displays obsessive-compulsive behavior. Clients w/disorder are aware that their behavior is excessive & are unable to stop behavior.

THIS phrase is an example of offering general leads:

THIS: And after that?

Rationale: The technique of offering a general lead offers client encouragement to continue conversation.

What Secondary Prevention Strategy interventions should nurse plan to include for clients experiencing partner violence?

Strategy: Coordinating community resources for hospitalized client.

Rationale: Secondary prevention strategies include intervening for client currently experiencing partner violence, counseling client, & arranging a move to a safe house.

Caring for adult client involuntarily admitted following a suicide attempt. Nurse receives call from client's spouse asking for status report. Nursing Response:

Nursing Response: I cannot discuss your spouse's health information w/o his consent.

Rationale: HIPAA protects client privacy regardless of admission status. Client can approve individuals w/ whom nurse can share information. Releasing protected health information w/o permission from client is an invasion of privacy & a HIPAA violation.

Example Technique to change unwanted behaviors:

Example Technique: Role Playing.

Rationale: Nurse can assign specific roles to clients & develop scripts to use when acting out different situations. This allows clients to see how behavior affects others & gives opportunity to practice new behaviors.

Caring for client w/hoarding disorder involving food. Priority Action:

Priority Action: Assist client w/completing Hoarding Scale Self Report.

Rationale: This provides data on severity of hoarding behavior.

Client w/Mania placed in seclusion d/t escalating behavior. Nursing Action:

Nursing Action: Check physical needs Q15mins.

Rationale: Assess & document client's physical, comfort, & safety needs Q15mins to minimize risk of injury & provides a legal record of care received.

Nurse assisting in obtaining informed consent from client scheduled for Vagus Nerve Stimulation. Nursing Action as a client Advocate?

Nursing Action: Ensure client signs form voluntarily.

Rationale: Nurse acts as client advocate by ensuring client gives consent voluntarily, appears competent to provide consent, & has received information about purpose, alternatives, risks, & benefits of procedure.

This Finding indicates Serotonin Syndrome:

This Finding: Hyperpyrexia

Initiate use of cooling blankets or other means to lower body temperature.

These 3 situations identify a requirement to report child/vulnerable adult maltreatment:

1) 7-year-old w/a variety of old & new bruises on his back & posterior thighs.

2) 2-year-old w/a spiral fracture of arm, parent states happened when falling from a swing.

3) An 80-year-old client w/dementia who lives in a group home & has bruises in perineal area.

Dietary teaching to client w/prescription for MAOI Tranylcypromine:

AVOID Avocados d/t High Tyramine content. This promotes release of Norepinephrine from sympathetic neurons. High Tyramine can result in a Hypertensive crisis d/t massive Vasoconstriction & excessive stimulation of heart. Levels are highest in very ripe Avocados.

Anticholinergic (Antiparkinson agent) Benztropine to ⬇EPS Monitor:

Monitor: Tachycardia

At risk for Palpitations & Tachycardia caused by anticholinergic toxicity.

Common adverse effects associated w/anticholinergic medications include dry mouth, blurred vision, urinary retention, constipation, photophobia, & tachycardia. Benztropine is commonly prescribed for clients taking antipsychotic agents & experiencing EPS; Pseudoparkinsonism w/tremors, Shuffling gait, Drooling; Dystonia w/painful contractions of jaw or neck.

Client w/Dependent Personality Disorder. Expect:

Expect: Avoids self responsibility. Has great need to be taken care of, leading to fears of separation, difficulty making decisions, & avoidance of taking responsibility for most aspects of life.

Medication given during Acute phase of Alcohol Withdrawal?

Medication: Benzodiazepine such as Diazepam to raise seizure threshold & prevent seizures, ⬇agitation, stabilize vitals, ⬇ intensity of withdrawal manifestations, & prevent delirium tremens.

4 Examples of Risk factors for child maltreatment?

1) Child born w/cleft lip & palate.

2) Having a congenital abnormality

3) Children younger than 3 years

4) Children from unwanted pregnancy

Caring for client w/generalized anxiety disorder who suddenly begins pacing, wringing hands, & reporting numbness/tingling fingers. Nursing Action:

Nursing Action: Walk w/client while setting physical limits on behavior.

Client is experiencing panic level anxiety & might display unsafe behavior during this time. Nurse should stay w/client & allow to walk around to ⬇ tension & anxiety.

Client w/Schizophrenia exhibits violent behavior. After staff members place client in restraints, which action should the nurse take?

Nursing Action: Request provider see client within 1hr.

Client has frequent episodes of aggressive & violent behavior. THESE 4 findings indicate client is at risk for imminent violence:

THESE Findings:

1) Uses profanity to express emotions.

2) Clenches & unclenches aw.

3) Maintains intense eye contact.

4) Paces floor.

Which task can be delegated to the AP?

Task: Remain w/client w/Anorexia Nervosa following a meal.

Rationale: At risk for purging following a meal. It is within the function of AP to remain w/client following meal to ensure client complies w/plan of care & does not purge.

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

15 mL

Nurse preparing to discharge client w/HTN who requires detoxification for alcohol use disorder. Recommend Referral to THIS resource:

THIS: A residential rehabilitation program.

Rationale: These programs have a 24hr medical staff & provide specialized care for clients w/comorbid conditions.

Nurse in outpatient mental health facility assessing a family unit consisting of grandparents, parents, several children. THIS Tool can assist in assessing this group of clients?

THIS Tool: Genogram

Rationale: Assess current & past functioning of a family unit of several generations. Collect information about where family lives, educational level of members, occupations, information about medical, emotional, & behavioral status.

What is an Advantage of taking Buspirone over other AntiAnxiety medications?

Advantage: It does not cause physical dependence.

Rationale: Unlike other antianxiety agents, Buspirone is not a CNS depressant. Does not cause physical or psychological dependence & does not produce tolerance.

Intervention to include in plan of care for a client w/PTSD:

Intervention: Assign same staff to care for client.

Rationale: Clients w/PTSD can be suspicious of others in their environment & assigning same staff will facilitate a trusting relationship.

Nurse in a mental health clinic receives phone call from client w/mental health disorder who lives at home; reports they cannot afford to refill prescriptions for antipsychotic medication requesting assistance. What member of health care team should nurse Notify?

Notify: Case Manager

A case manager/social worker coordinates care for a client w/mental health disorder, including sources of financial aid. Can provide care in client's home, school, or place of employment. Can also include medication monitoring & guidance w/community services.

Nurse is reviewing a LAB report of client taking 2ndGenOlanzapine. What LAB value should be reported to provider?

LAB: Fasting Glucose 140 mg/dL.[Range:74-106]

Rationale: 2ndGenOlanzapine is prescribed for Schizophrenia. An adverse effect is Hyperglycemia.

By what Mechanism does 2ndGenOlazapine cause Hyperglycemia?

Mechanism: Evidence suggests 2ndGenOlanzapine may impair pancreatic β-cell function, which reduces insulin secretion. Less insulin → glucose cannot be cleared from blood efficiently.

Include THIS statement when discussing Legal issues w/new nurse:

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

Rationale: Nurses should report a client's threat to provider, provider has legal obligation to notify third parties when client threatens serious harm.

Nurse in acute care mental health facility is preparing client for discharge. Include this Task in termination phase of nurse-client relationship?

THIS Task: Make appropriate referrals.

Rationale: During termination phase of nurse-client relationship, nurse should make referrals to appropriate agencies for client to contact if they need help in future.

Nurse is providing education for the family of a client w/Dementia. Include THIS Intervention:

THIS Intervention: Limit fluid intake after evening meal.

Rationale: Educate family to limit client's fluid intake after evening meal around 1800. Family should offer fluids Q2hrs during day to prevent dehydration, & to minimize nighttime incontinence, they should limit or restrict fluid intake after 1800.

Client w/Bipolar experiencing Mania. THIS is Priority finding:

THIS: Client refuses to drink fluids.

Rationale: Severe dehydration can cause cardiac arrhythmias d/t fluid & electrolyte imbalances. Nurse should continue to offer client fluids at least once per hour, & encourage client to drink fluids using a clean and calm tone.

Client w/Bipolar takes Anticonvulsant Anti-epileptic Mood stablilizer Carbamazepine. Monitor for these CNS Adverse Effects:

Adverse Effect: Ataxia

Rationale: CNS adverse effects are common during first few weeks of taking Anticonvulsant Anti-epileptic Mood stabilizer Carbamazepine.

Including Vertigo, Ataxia, Drowsiness, Diplopia

5 Manifestations of Ataxia?

1) Unsteady or staggering gait

2) Poor balance

3) Difficulty coordinating movements

4) Slurred speech

5) Trouble w/ fine motor tasks

Caring for school age child w/Lacerations & Bruises inflicted by mother. Father states, "My wife was fired today & came home angry. I don't think this will ever happen again." Nurse Response:

Nurse Response: Your child will be privately interviewed about the incident.

Rationale: To allow child opportunity to discuss situation accurately in his own words. Presence of a parent during interview can influence child's responses.

Nurse is counseling a client w/ alcohol use disorder who chose to enter a treatment program. Clients states, "I need to find a program that won't interfere w/my job." Identify THIS community resources as being least restrictive?

THIS: Outpatient treatment program.

Rationale: When using least restrictive framework, identify an outpatient treatment program provides least restrictive for alcohol use disorder treatment.

Providing morning care for a client w/Alzheimer's w/frequent outbursts of aggression. Nursing Action:

Nursing Action: Limit the client's choices.

Rationale: Asking client to choose between 3 or 4 options can lead to anxiety & agitation; If client is capable of making choices, limit choices to no more than 2 at a time, such as making decisions about eating & getting dressed.

Client w/Schizophrenia experiencing frequent Delusions. Strategy:

Strategy: Identify client's feelings underlying delusions.

Rationale: Focus on underlying feelings, rather than on illogical aspects of Delusion. Encourage to talk about fears & anxieties relating to Delusion w/o any assumptions/statements about Delusion being

real/ false.

Client's partner died 3 years ago. Client has withdrawn socially & has not participated in regular activities since funeral. What type of grief is client displaying?

Chronic grief

Rationale: Occurs when there is a prolonged emotional instability, a withdrawal from usual tasks or activities, & lack of progression to successful coping w/loss.

What medication is treatment for smoking cessation?

Medication: Norepinephrine-Dopamine Reuptake Inhibitor Bupropion

Rationale: An atypical antidepressant, for nicotine withdrawal. Reduces addictive action of nicotine & can minimize manifestations of withdrawal.

Client w/Schizophrenia & Heart failure. Which resource addresses client's behavioral health & medical needs?

Resource: Patient-centered medical home (PCMH)

Rationale: Provides behavioral health & medical services. Offers extended hours of service 7 days/week w/comprehensive patient-centered care. Clients receive comprehensive, supportive community & social services.

Priority finding during assessment of client w/Schizophrenia:

Finding: Command hallucinations

Rationale: Greatest risk is injury to self or others d/t command hallucinations. Occurs when client hears inner voices telling them to take an action, such as self harm or harm to others. Ask client what voices are telling them to do.

Teaching about biofeedback therapy. THIS statement indicates an understanding of teaching:

THIS: This therapy will help me recognize changes in my BP

Rationale: Purpose of biofeedback therapy is to enable clients to learn to consciously control body processes.

Client experiencing mild anxiety. Expect:

Expect: Sharpened perceptions.

Rationale: Mild anxiety occurs during normal daily experiences & allowing individuals to grasp more information & problem-solve more effectively. As stress increases, perceptual field narrows & are eventually only able to focus only on anxiety source.

THIS Question assesses Cognition:

Question: What did you have for dinner last night?

Rationale: Assess client's cognitive status by asking questions that test client's recent & immediate memory, such as what they had for dinner.

Nursing intervention for client w/Anorexia nervosa:

Intervention: Weigh daily after first voiding.

Rationale: Weigh each morning after waking & following first voiding. Client should have nothing by mouth, including water, before obtaining weight.

The client exhibits yawning, pupillary dilation, rhinorrhea, & reports muscle cramps. Which substance is client withdrawing from?

Opioid Heroin

Rationale: Manifestations of Opioid Withdrawal includes severe muscle cramps, yawning, rhinorrhea, & Wide/Pupillary Dilation. Occurs within 6-8hrs after last dose following a period of at least 1 week of use.

Family member reports client has change in behavior over past 2 days. THESE Findings indicate Delirium:

THESE Findings:

Change in LOC

⬇ attention span

Hallucinations

THIS response demonstrates understanding of elder abuse:

THIS: Older adults dependent on a caregiver might be at an ⬆ risk for abuse.

Rationale: Caregiver strain can ⬆ risk for elder abuse. An older adult dependent on others for care d/t poor physical health, or a chronic disease such as Alzheimer's disease, also ⬆ risk for abuse.

Client w/Schizophrenia experiencing Visual Hallucinations states, "That man on the ceiling is ridiculing me." Nurse Response:

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

Rationale: Use therapeutic communication to address client's hallucinations & delusions. Offer own perception of what client is seeing or hearing w/o negating client's experience.

Expected Finding w/Opioid withdrawal:

Expected: Tachypnea

Other manifestations of Opioid Withdrawal include Hyper-Reflexia, Enlarged pupils, Muscle spasms, Lacrimation, Yawning, Rhinorrhea.

Medications that treat symptoms for Alcohol Withdrawal:

Medication: Benzodiazepine Lorazepam which:

Enhances GABA activity

Produces sedation

Reduces CNS hyperexcitability

Which client is experiencing an Adventitious crisis?

A client who recently lost their home in a fire.

Rationale: An adventitious crisis is caused by an unplanned event, such as a fire, earthquake, riot, plan crash, or violent crime.

Expected Finding in client w/Dependent Personality Disorder:

Expected: Fear of being abandoned by others.

Other manifestations include Submissiveness & Desire to be cared for.

Example of a stress management Technique for anxiety disorder:

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

Caring for client whose partner recently died. Nursing Action:

Allow client to experience & express grief in personally unique ways.

Assessing client whose child died 1 year ago. THIS finding indicates client might be experiencing major depressive disorder rather than an expected grief response?

THIS: Loss of self-esteem d/t feelings of worthlessness.

Rationale: Expected grief responses include an intact self-esteem, focus on deceased; feelings of sadness that decreases over time.

Client w/Schizophrenia w/auditory hallucinations. Nursing Action:

Nursing Action: Redirect client's attention using reality based conversation.

Rationale: Using a calm voice, provide a diversion from hallucinations by engaging w/simple conversation.

Teaching to family of client w/moderate Alzheimer's disease:

Teaching: Consider using respite care.

Rationale: These services allow time to rest/strengthen ability to be a caregiver. Long term illness affects mental, physical, emotional, & spiritual health.

Nursing Response for client expressing anger/fear about job loss.

Response: What are some ways you can deal w/ job loss?

Rationale: Nurse can then encourage to identify plan of action for addressing situation.

Nursing Intervention for client w/Bipolar experiencing Mania:

Intervention: ⬇ volume of TV in dayroom.

Also dim bright lights & avoid placing client in a group of people.

Different types of therapeutic support groups; Bereavement:

THIS support group helps clients experiencing loss.

Client takes Antipsychotic Fluphenazine received dose of Antiparkinson Benztropine to treat an Acute Dystonic reaction. THIS indicates Benztropine is effective:

Decrease in facial muscle spasms.

Rationale: Benztropine treats acute dystonic reactions, an adverse effect of antipsychotic medications such as Fluphenazine. Acute dystonic reactions causes painful contractions of face, tongue, jaw, neck, & back.

Nurse is preparing to administer SSRI Escitalopram to client taking St. John's wort 1hr ago. Nursing Action:

Hold dose of Escitalopram & consult provider.

Rationale: St. John's wort can ⬆ risk of Serotonin Syndrome when combined w/SSRIEscitalopram.

Assessing client w/Schizophrenia Observes lip smacking, jaw clenching; repeated tongue protrusions. THIS medication is potential cause of these findings?

THIS: Haloperidol

Rationale: These findings indicate Tardive dyskinesia, a potential adverse effect of antipsychotic medications like Haloperidol.