ATI Mental Health Review

ATI Mental Health Review – Western Governors University A 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. Answer: D It is the charge nurse and the nurse manager's responsibility to confront the staff member about her behavior toward the client. A nurse is caring for a client who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism? A) "I will limit my drinking to the weekends." B) "I will stay in my room and avoid others when I'm feeling down." C) "I will be dependent on others for the time being." D) "I will attend daily group therapy sessions to practice relaxation techniques." Answer: D Relaxation techniques decreases the risk for self-harm by decreasing stress, anxiety, and depression. 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. Answer: C The nurse should frequently offer the client, high-calorie foods that can be eaten while on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration. A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? A) Have a family member present during treatment. B) Increase fluid intake. C) Change position slowly. D) Wear sunglasses when outdoors. Answer: D Light therapy, or phototherapy, can cause eye strain and sensitivity to light. A nurse in a community health center is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A) Repeatedly talks about the traumatic episode. B) Sleeps excessively. C) Experiences feelings of isolation. D) Uses repetitive speech. Answer: C Clients who have PTSD often feel estranged and detached from others. A nurse is creating a plan of care for a client who has been 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/hr. C) Renew the prescription for the client every 4 hours. D) Toilet the client every 4 hours. Answer: C 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 planning prevention strategies for intimate partner abuse 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 legal advocacy program. D) Organize rehabilitation therapy for clients who have experienced intimate partner abuse. Answer: B This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for intimate partner abuse in the community and can take the necessary steps to address individual client needs. 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 Answer: A St. John's Wort is an herbal preparation that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John's Wort with another medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome. 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. Answer: A The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-to-one observation to promote client safety. A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, she does not respond. Which of the following actions should the nurse take before repeating the request to the client? A) Allow the client time to collect her thoughts. B) Prompt the client to give a response. C) Move on to the next client. D) Offer the client a suggestion for a goal. Answer: A Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question. 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 Answer: D Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect. 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 his 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 he feels accepted Answer: A Client's who have dependent personality disorder need excessive input from others to make everyday decisions. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her 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 perceptual disturbance. D) Convince the client that there is not bomb in her room. Answer: C The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions). A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the groups time. Which of the following interventions should the nurse implement? A) Tell the client that he must talk less or he will be removed from the meeting. B) Ask group members to discuss their feelings about this client's monopolizing behavior. C) End the group meeting and take the client aside to discuss his behavior. D) Focus on other group members and ignore the client who is doing all the talking. Answer: B This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority? A) Encourage expression of feelings. B) Promote attendance at an assertiveness training group. C) Assist the client to perform relaxation breathing. D) Use a therapeutic holding techniques Answer: D The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to use a therapeutic holding technique to de-escalate the behavior and prevent injury. A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? A) "She works so hard at ballet. Will she still be able to perform?" B) "She won't let me take the trash from her room. I'm concerned about what she has in there." C) "She told me she was tired, so I did her chores for her today." D) "She is happier with her appearance now that she's lost some weight." Answer: B The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statement indicates awareness of her daughter's behavior. 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? A) Slow onset B) Aphasia C) Confabulation D) Easily distracted Answer: D Extreme distractibility is a hallmark manifestation of delirium. 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, "That man in my room never sleeps and he keeps me up, too." Which of the following is an appropriate action for the nurse to take? A) Move the client who has bipolar disorder to a private room. B) Administer sleep medication to the client who has bipolar disorder. C) Move the client who has severe depression to a private room. D) Administer sleep medication to the client who has severe depression. Answer: A Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room. A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A) An adolescent family member who questions parental authority. B) A family with three generations in the same household. C) Older children who are responsible for their younger siblings. D) Two adults and their children from prior relationships in the same household. Answer: C This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members. 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? A) Administer phenytoin 30 min prior to the procedure. B) Instruct the client to expect a headache following the procedure. C) Place the client in four point restraints prior to the procedure. D) Monitor the client's cardiac rhythm during the procedure. Answer: D The seizure induced during ECT can stress that client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram. A: The nurse should not plan to administer phenytoin, an anticonvulsant medication, to a client prior to ECT. The purpose of ECT is to induce a short seizure by stimulating the brain with an electrical current. 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? A) Panic B) Moderate C) Severe D) Mild Answer: D The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information. A client who has bipolar disorder to be discharged home with a prescription for lithium. Which of the following statements indicates that client teaching regarding the medication has been effective? 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." Answer: A This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. 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? A) The program will help the client accept responsibility for his disorder. B) The client should obtain a sponsor before discharge for an increased chance of recovery. C) The client will need to identify individuals who have contributed to his disorder. D) The program will need a prescription form the client's provider prior to attendance. Answer: B The nurse should teach the client to secure a sponsor because the client-sponsor relationship has been shown to increase program attendance and the chances of recovery. A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery? A) "I consciously decrease my breathing rate when I feel anxious." B) "I am riding my bike around the neighborhood every day." C) "I find at least one positive thing in situations that upset me." D). "I imagine myself lying on a quiet beach when I start to feel anxious." Answer: D Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery. 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. Answer: C The nurse should question clients in a private when conducting interviews regarding client health. A nurse is caring for a client who has a recent diagnosis of Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? A) Inability to recognize family members. B) Chooses clothing that is inappropriate for the weather. C) Exhibits a change in personality. D) Frequently misplaces objects. Answer: D According to evidence-based practice, the nurse should identify that mild congestive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following places the client at the greatest risk for self-directed injury or injuring others? A) Inability to communicate with others. B) Feelings of absence of self-worth. C) Lack of motivation to perform daily tasks. D) Command hallucinations. Answer: D A client who has schizophrenia and is experiencing command hallucinations can hear voices telling him to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at greatest risk for self-directed injury or injury to others. A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply) A) Occupational therapy B) Meal delivery services C) Speech therapy D) Physical therapy E) Home health services Answer: A, B, D, E 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? A) Allowing a client to choose which unit activities to attend. B) Attempting alternative therapies instead of restraints for a client who is combative. C) Providing a client with accurate information about his prognosis. D) Spending adequate time with a client who is verbally abusive. Answer: D By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care. 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? A) The client is married. B) The client recently received a promotion at work. C) The client has COPD. D) The client is a male. Answer: C Clients who have a medical illness are at an increased risk for the development of depression. 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 dietitian for a calorie-controlled diet plan. D) Recommend that the client exercise regularly. Answer: B The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial therapy. A charge nurse enters a client's room and observes an assistive personnel (AP) slapping an older client. After moving the client to safety, which of the following actions is the charge nurse's priority? A) Complete an incident report. B) Determine if the client has been physically harmed. C) Provide emotional support to the client. D) Discipline the AP. Answer: B The greatest risk to this client is injury. Therefore, the priority intervention the charge nurse should take is to determine if the client has injuries that need attention. 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 Answer: A Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chloropromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies.. Do not use a trailing zero.) Answer: 14 mL A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following findings should the nurse expect? A) The client was seriously injured while under the influence of alcohol. B) The client has a history of panic attacks. C) The client chose to drop out of college a few months ago. D) The client works a stressful job at an international bank. Answer: A Traumatic events that causes severe stress is a trigger for dissociative amnesia. 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? A) "I will use the same plan of care and interventions for each client who has depression." B) "Each individual nurse will develop a separate plan of care when managing clients who have depression." C) "I will update the plan of care as a client's manifestations of depression change." D) "An assistive personnel can use the plan of care for client teaching." Answer: C The nurse should update the plan of care as a client's status and needs change. A nurse is caring for a client who have birth to a stillborn baby. Which of the following statements should the nurse make? A) "You probably want to hold your baby." B) "I'll stay with you just in case you want to talk." C) "I know how you must be feeling." D) "It hurts now, but things will be better soon." Answer: B This response indicates the nurse's interest in the client and a desire to understand the client's feelings. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A) Orient the client to person, place and time. B) Assist the client with deep-breathing exercises. C) Calm the client by using therapeutic touch. D) Have the client sit alone in a quiet room. Answer: B Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. A nurse is teaching a family member and a client who has a new diagnosis of Alzheimeer's disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? A) "Take this medication in the evening at bedtime." B) "Expect this medication reverse the effects of Alzheimer's disease." C) "If you miss a dose double the next dose." D) "You can crush this medication in applesauce." Answer: A The client should take this medication in the evening at bedtime for optimal effectiveness. A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority? A) Decrease distractions 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. Answer: D The greatest risk to the child who has ADHD is