VATI PN Mental Health Assessment

A nurse is assisting with the care of a client immediately following electroconvulsive therapy (ECT). Which of the following findings should the nurse document as an unexpected response to the procedure?

Irregular heart rhythm

An irregular heart rhythm is an unexpected response to ECT. During the procedure, the client's heart can be stressed, which can cause cardiac abnormalities. especially if the client already has impaired cardiac function. The nurse should document this finding and notify the charge nurse or the client's provider.

A nurse is caring for a client who is admitted for alcohol use disorder. The client states, "I have not had anything to drink for 24 hours." Which the following is the priority nursing intervention?

Check the client's vital signs.

Clients who have alcohol use disorder are at risk for the development of abstinence syndrome. Manifestations of abstinence syndrome occur 12 to 72 hr after the client has last consumed alcohol and can include tachycardia, hypertension, and an elevated temperature. Therefore, the first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to check the client's vital signs to monitor for signs of abstinence syndrome.

A nurse is reinforcing teaching with the adult child of a client who is scheduled to have electroconvulsive therapy (ECT). Which of the following statements should the nurse make?

"Your father might experience short-term memory loss after the procedure."

The nurse should reinforce to the client's child that short-term memory loss is a common adverse effect of ECT.

A nurse is assisting with planning care for a client who is in the manic phase of bipolar disorder. Which of the following actions is the priority for the nurse to include in the plan?

Offer frequent high-calorie fluids throughout the day.

The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for food and fluids. The priority nursing action is to frequently.offer the client high-calorie fluids to prevent dehydration and ensure the client's caloric is adequate to meet intake physical needs.

A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. Which of the following manifestations should the nurse instruct the client to report to the provider as an adverse effect of this medication?

Abdominal pain

The nurse should instruct the client that abdominal pain can indicate hepatoxicity or pancreatitis, both adverse effects of valproic acid; therefore, the client should report this to the provider.

A nurse is establishing a therapeutic relationship with a client who has generalized anxiety disorder. Which of the following actions should the nurse take first?

Explain confidentiality guidelines to the client.

Evidence-based practice indicates that the nurse should first begin a therapeutic relationship with the orientation phase. During this phase, the nurse should explain the guidelines for confidentiality. This initial step in developing a therapeutic relationship builds trust between the client and the nurse.

A nurse is interviewing an adolescent client who reports that they were sexually assaulted. Which of the following actions should the nurse take?

Move the client to a private examination room to perform the interview.

The nurse should interview the client in a private room without others present. Providing privacy in a safe environment will foster trust and promote open communication between the client and the nurse.

A nurse is caring for a client who is experiencing a severe panic attack. Which of the following actions should the nurse take during the panic attack? (Select all that apply.)

Stay with the client is correct. The nurse should stay with the client during the panic attack to ensure that the client remains safe and reduce feelings of abandonment.

Instruct the client to take slow, deep breaths is correct. The nurse should instruct the client to breathe slowly and deeply to distract from the distressing manifestations of the attack and reduce the risk for hyperventilation.

Set physical limits is correct. The nurse should set physical limits to maintain the safety of the client and others because the client might have difficulty controlling their actions during the attack.

A nurse is collecting data from a 5-year-old child who is brought to the emergency department by a parent who states that the child fell out of a tree. The child is guarding their right arm. For which of the following findings should the nurse suspect physical maltreatment?

An x-ray of the right arm indicates a spiral fracture.

The nurse should identify that an x-ray indicating a fracture can be an expected finding for a child who fell out of a tree. However, a spiral fracture is caused by twisting of the extremity and can be an indication of physical maltreatment. The nurse should report the findings to the registered nurse.

A nurse is reinforcing discharge teaching with the family of a client who has mild dementia. The family plans to care for the client in their home. Which of the following instructions should the nurse include?

Use signs to identify different rooms in the home.

The nurse should reinforce the need to label the bathroom as well as other rooms in the home. The use of signs using words and pictures promotes independence and orientation by providing reminders for the client.

A nurse is reinforcing teaching with a client who is preparing for a conditional release following involuntary admission. Which of the following statements by the client indicates an understanding of the teaching?

"IF I don't follow the instructions in my conditional release, I might be readmitted."

A client who is being discharged on a conditional release following involuntary admission must adhere to additional treatment plan requirements after discharge. If the client does not follow this treatment plan, they might be readmitted to the mental health facility.

A nurse is contributing to the plan of care for a client who has moderate Alzheimer's disease and is neglecting personal hygiene. Which of the following interventions should the nurse include in the plan?

Assign an assistive personnel (AP) to help the client with personal hygiene.

A client who is in this stage of Alzheimer's disease has difficulty with or is unable to perform self-care. The nurse should assign an AP to assist with the client's personal hygiene.

A nurse is reinforcing teaching regarding family therapy with the parents of a client who has anorexia nervosa. The parents tell the nurse, "We don't understand why we have to have family therapy when we are not sick." Which of the following responses should the nurse provide?

"Family therapy explores how the family dynamics impact your son."

Clients who have anorexia nervosa often have troubled relationships with family members, and family therapy can help to strengthen those relationships. Resolution of the client's illness is unlikely to occur until family dynamics improve.

A nurse is collecting data from a client who received diazepam 10 mg PO 1 hr ago. Which of the following findings should the nurse identify as an indication that the client is experiencing benzodiazepine toxicity?

Respiratory rate 10/min

The nurse should identify that a respiratory rate of 10/min is below the expected reference range of 12 to 20/min, indicating bradypnea. Benzodiazepine toxicity causes CNS depression and can lead to coma and death.

effects should the nurse A nurse is reinforcing teaching with a client who has schizophrenia and a new include in the teaching? (Select all that apply.) prescription for fluphenazine. Which of the following adverse

Akathisia is correct. Akathisia, or restlessness, is an adverse effect of fluphenazine. Akathisia is one of several extrapyramidal side effects (EPS) that occur with fluphenazine. Other EPS include pseudoparkinsonism, akinesia, dystonia, and tardive dyskinesia.

Hypotension is correct. Orthostatic hypotension is an adverse effect of fluphenazine.

Drowsiness is correct. Drowsiness is an adverse effect of fluphenazine.

A nurse is planning an in-service about eating disorders for a group of staff nurses. Which of the following conditions should the nurse include as a risk factor for anorexia nervosa?

A diagnosis of obsessive-compulsive disorder

The nurse should include that a diagnosis of obsessive-compulsive disorder is a risk factor for anorexia nervosa. Other factors that can predispose a client to developing anorexia nervosa include alterations in serotonin levels and a desire for perfection.

A nurse is contributing to the plan of care for a client who has anorexia nervosa and is 60% of their ideal body weight (IBW). Which of the following interventions should the nurse include?

Set structured mealtimes for the client.

The nurse should provide a structured environment for the client, including setting specific mealtimes. This allows the client to learn and adapt to a more regular eating pattern.

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of veracity?

Informing a client about the adverse effects of a prescribed treatment This action demonstrates the ethical concept of veracity.

The nurse should ensure that the client receives truthful information about treatment. Reinforcing accurate information promotes trust in the nurse-client relationship and allows the client to make informed decisions about their health care.

A nurse is admitting a client to a mental health unit. The nurse should inform the client that they have which of the following rights? (Select all that apply.)

The right to retract previously provided consent is correct. The client has the right to retract consent for treatment or therapies, whether written or verbal. However, this is dependent on the client's level of competency, because a client who is deemed incompetent is unable to make their own health care decisions.

The right to receive individualized care is correct. The client has the right to treatment, which includes receiving high-quality care and being involved in their own care in order to collaborate on treatment decisions.

The right to refuse psychotropic medications is correct. The client has the right to refuse treatment and medications, including psychotropic medications. The client might receive emergency psychotropic medications if they are an imminent danger to themselves or others. However, a court of law must then determine if the client can receive additional psychotropic medication against their will.

The right to the least restrictive environment is correct. Federal law states that a client has the right to treatment, including the right to the least restrictive environment. Physical or chemical restraints or seclusion should be implemented when other methods of intervention are ineffective and the client is a danger to themselves or others.

A nurse is contributing to the plan of care for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse recommend?

Initiate seizure precautions for the client.

The nurse should expect a client who is experiencing acute alcohol withdrawal to be at risk for seizures. Therefore, the nurse should recommend placing the client on seizure precautions to reduce the risk for client injury if a seizure occurs.

A nurse is caring for a client who takes haloperidol. The nurse should expect that the provider will prescribe which of the following laboratory tests?

Liver function

The nurse should expect that a client who is taking haloperidol will have liver function tests every 6 months. Haloperidol is a conventional, first-generation antipsychotic medication that can cause cholestatic jaundice.

ostudent.atitesting.com/Assessment A nurse is caring for a client who has schizophrenia and reports anxiety due to hearing voices. Which of the following actions should the nurse take?

Encourage the client to listen to music using headphones.

The nurse should encourage the client to use competing auditory stimuli, such as music or television, that can minimize the auditory hallucinations and reduce the client's anxiety.

A nurse is collecting data from a client who has schizophrenia. When asked questions, the client keeps repeating what the nurse says rather than providing answers. The nurse should document this finding as which of the following alterations of speech?

Echolalia

The nurse should document the client's repetition of what the nurse says as echolalia. This alteration of speech is characterized by continual repeating of what is spoken to the client. For example, if the nurse says, "It's time for your therapy session." a client exhibiting echolalia will repeat, "It's time for your therapy session."

A nurse is reinforcing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following statements by the client indicates an understanding of the teaching?

I will have the level of medication in my blood checked regularly."

The nurse should instruct the client to have their lithium levels checked according to the provider's plan while taking this medication, Lithium has a narrow therapeutic range of 0.8 to 1.2 mEg/L.

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse report to the provider immediately?

The client sleeps about 2 hr per night.

Bipolar disorder is a complex mood disorder characterized by cycles of depression and mania. In the manic state, clients have boundless energy and neglect physical needs such as sleep. The greatest risk to the client is physical exhaustion, which could result in death. The nurse should immediately report this finding to the provider.

A nurse is preparing to collect data from a client who has delirium. Which of the following findings should the nurse expect?

Disorientation that fluctuates

Disorientation that fluctuates is an expected finding for a client who has delirium. Other expected findings include an inability to focus and disorganized thinking. The client might also be either hyperactive, hypoactive, or a combination of the two.

A nurse is caring for a client who is obese and states, "I need to lose weight to be attractive again." Which of the following actions should the nurse take first to promote positive self-esteem?

Ask the client how they feel about their weight and appearance.

The first action the nurse should take when using the nursing process is to collect data from the client. By identifying the client's feelings about their weight and appearance, the nurse can determine the client's specific concerns and provide interventions that meet the client's individual needs.

A nurse is collecting data from a client who has depression. Which of the following findings should the nurse expect?

Poor concentration

The nurse should identify that clients who have depressive disorders can experience indecisiveness and difficulty concentrating.

A nurse is caring for a client who has insomnia disorder. Which of the following actions should the nurse take?

Establish a routine that signals the end of the day.

The nurse should establish a routine for the client that takes place before sleep that signals the end of the day. This can help to prepare the client's body for sleep, which can alleviate insomnia.

A nurse is caring for a client who is experiencing a paranoid delusion. The client is becoming increasingly anxious. Which of the following interventions should the nurse take?

Ask the client to describe the delusion.

Delusions are false personal beliefs that persist regardless of the proof to the contrary or how irrational the belief is. A client who is experiencing paranoid delusions is suspicious of others and their motivations, believing there is an intent to cause the client personal harm. The nurse should ask the client to describe the delusion and address its underlying themes to better understand what the client is experiencing.

A nurse is collecting data from a client who is seeking help regarding their sexuality. Which of the following statements by the client should the nurse identify as a finding of hypoactive sexual desire disorder?

"My libido is not as strong as it used to be."

Hypoactive sexual desire disorder is characterized by a lack of sexual desire, and can be caused by psychological, hormonal, and psychosocial factors. This statement by the client indicates a recognition on the part of the client that there has been a decrease in their level of sexual desire.

A nurse is reinforcing teaching with a client who has a prescription for a monoamine oxidase inhibitor (MAOI). Which of the following lunch choices by the client indicates an understanding of the teaching?

An egg salad with a sliced tomato and a yeast roll

The client should avoid foods that are high in tyramine because they can interact with MAOis and cause a hypertensive crisis. Tomatoes, eggs, and yeast rolls are acceptable dietary choices because they contain little or no tyramine.

A nurse in a long-term care facility is caring for a client who has dementia and cannot verbalize their wants and needs. The client refuses to drink liquids provided on meal trays. Which of the following actions by the nurse demonstrates advocacy?

Ask the client's family what their favorite beverages are.

Nurses develop therapeutic relationships with clients over time and can include family members of the client when planning care. The nurse should advocate for the client by attempting to find out their preferences so the dietary and nursing staff can provide preferred beverages at meals.

A home health nurse is reinforcing teaching with the family members of a client who has Alzheimer's disease and is experiencing sleep disturbances. Which of the following instructions should the nurse include?

Wake the client at the same time each morming.

The nurse should instruct the family to wake the client at the same time every day to establish a consistent sleep-wake schedule.

A nurse is caring for a client who says, "I quit taking my lithium. I did not like the way I felt on that drug." Which of the following responses should the nurse make?

"How do you feel when you take the medication?"

encouraging the client to describe their perception of the medication's adverse effects. This is a therapeutic communication technique in which the nurse asks an open-ended question to obtain further information from the client. The nurse is also

A nurse is discussing confidentiality with a client who was just admitted to an acute mental health unit. Which of the following client statements indicates an understanding of the teaching?

"You have to report it if I threaten to hurt anyone.

The nurse has a legal and ethical obligation to maintain a client's confidentiality. The client's confidential information is protected by HIPAA. However, there are exceptions to this rule, including the duty to warn and the reporting of abuse. If a client states that they have the intent to harm any individual, the nurse has the legal obligation to ensure that the person who was threatened is notified of this threat so necessary protective actions can be taken.

A nurse is caring for a client who is experiencing acute alcohol withdrawal. The client becomes agitated, and the nurse administers lorazepam 2 mg IM. Which of the following actions should the nurse take?

Ensure a staff member remains with the client continuously.

The client needs continuous evaluation and observation during the acute alcohol withdrawal phase due to the risk for harm to themselves or others.

A nurse is caring for a client who recently experienced a traumatic event. The nurse should identify that which of the following is an example of the client using repression as a defense mechanism?

The client reports not being able to remember anything about the event.

The nurse should identify the use of repression as a defense mechanism when the client reports not being able to remember anything about a traumatic event after it occurs. Repression is the unconscious process of blocking unpleasant or traumatic memories to avoid addressing the emotions associated with them.

A nurse is caring for a client who has schizophrenia. The client is refusing to participate in the current group activity. Which of the following statements should the nurse make?

"You do not have to participate right now if you don't feel comfortable."

Clients who have schizophrenia often have difficulty interacting with others. The nurse should allow the client to observe the group until they feel comfortable participating. This response by the nurse is therapeutic because it indicates acceptance of the client's feelings.

A nurse is caring for a client on a mental health unit and receives a call from the client's sibling requesting information regarding the client's condition. The client has not listed anyone on the release-of-information form. Which of the following actions should the nurse take?

Tell the caller that information cannot be released regarding their request.

The nurse must identify that the only individuals who have a right to a client's personal health information are those directly involved in the client's care and any individuals the client lists on the release-of-information form. Telling the caller that information cannot be released regarding their request protects the confidentiality of the client.

A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of the following findings should the nurse expect?

Restlessness

Clients who have GAD can be irritable and restless. They tend to worry excessively, far more than events or situations warrant.

A nurse is caring for a client who has Parkinson's disease. The client states, "Everything is looking pretty grim for me." Which of the following is the priority action for the nurse to take?

Ask the client if they have a specific plan for suicide.

The nurse should recognize that having a plan for suicide indicates that the client is at greatest risk for self-harm. Therefore, the priority action for the nurse is to determine if the client has a specific plan for suicide.

A nurse is caring for a client who frequently displays manipulative behavior. Which of the following actions should the nurse take?

Establish consequences for the client's actions.

Setting limits and establishing consequences for the client's behavior are effective forms of behavior modification for a client who displays manipulative behavior

A nurse is caring for a client who has early dementia and is prone to wandering at night. Which of the following strategies should the nurse use to help keep the client safe?

Place the client's mattress on the floor.

The nurse should place the client's mattress on the floor, which reduces the risk for injuries from falls during periods of confusion when the client engages in wandering behaviors.

A nurse is collecting data from a client who is taking paroxetine. Which of the following adverse effects should the nurse identify as the priority?

Confusion

The greatest risk for a client who is taking paroxetine is hyponatremia, which can be life-threatening. Confusion is a manifestation of hyponatremia. Therefore, this is the priority finding the nurse should report to the charge nurse and provider

A nurse is reinforcing teaching with a newly licensed nurse about the guidelines for use of mechanical restraints. Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching?

"I should apply mechanical restraints on a client who is attempting to harm themselves prior to obtaining a prescription."

The nurse should reinforce that mechanical restraints are safety devices that protect the client from committing harm to themselves or others. Once a client is in restraints, the nurse should obtain a prescription for the restraints from the provider.

A nurse is caring for a client following a modified radical mastectomy. Which of the following client statements is an indication of effective coping?

"I am planning to attend a support group after I leave the hospital."

The nurse should identify that making plans to attend a support group to assist with adaptation to the client's new body image is an effective coping strategy.

A nurse is reinforcing discharge teaching with a client who has alcohol use disorder. Which of the following statements by the client indicates an understanding of relapse prevention?

"I'm learning which situations I have difficulty handling."

Relapse prevention involves a multitude of skills, such as identification of triggers and stress management skills. Identifying factors contributing to alcohol consumption, such as stressful situations, can assist in preventing relapse.

A nurse is caring for a newly admitted client who has a diagnosis of schizoid personality disorder. The nurse should expect the client to exhibit which of the following behaviors?

Social isolation

The nurse should identify that a client who has a schizoid personality disorder is likely to exhibit social isolation and emotional detachment.

A nurse is updating the plan of care for a client who has dementia, After reviewing the documentation for the client, the nurse should recommend a referral to which of the following members of the interprofessional team?

Registered dietitian

Registered dietitians review a client's nutritional needs and adjust the client's diet based upon laboratory findings, medication adverse effects, and dietary intake. This client has an alteration in dietary intake, hypokalemia, and a low prealbumin level, which indicate that the client has malnutrition. Therefore, the client would benefit from a referral to a registered dietitian.