RN Mental Health ATI Practice
A college nurse is assessing a school-age child who skilled the worrying loss of a determine 8
months in the past. Which of the subsequent findings have to the nurse perceive as an
indication that the kid is experiencing submit-worrying strain disorder (PTSD)?
A. Clinging behaviors directed toward a instructor
b. Growth time spent drowsing
c. Intense awareness on faculty work
d. Lack of hobby in an upcoming excursion
D. Lack of hobby in an upcoming vacation
rationale: the child who has PTSD can have terrible moods an issue remembering aspects of
the traumatic occasion. The child also have loss hobby or lack of participation in extensive
activities and occasion along with vacations.
A nurse is worrying for a collection of customers. Which of the subsequent findings have to the
nurse record?
A. A consumer who is taking clozapine and has a WBC matter of 7,500/mm3 (5,000 to
10,000/mm3)
b. A purchaser who's taking lamotrigine and has advanced a rash.
C. A purchaser who is taking valproate and has a platelet be counted of two hundred,000/mm3
(one hundred fifty,000 to 400,000/mm3)
d. A consumer who's taking lithium and has multiplied thirst
b. A consumer who is taking lamotrigine and has advanced a rash.
Purpose: lamotrigine is an anticonvulsant medicinal drug this is used as a temper stabilizer. The
nurse ought to become aware of that a rash is a potentially life-threatening unfavorable effect of
the drugs and report this locating straight away.
A nurse is caring for a male client who has schizophrenia and is taking clozapine. Which of the
subsequent customer findings must the nurse perceive as a contraindication for receiving
clozapine?
A. WBC matter 2,500/mm3 (five,000 to 10,000/mm3)
,b. Hgb 11.Five mg/dL (14 to 18 g/dL)
c. Alogia
d. Client reviews having a dry mouth
a. WBC be counted 2,500/mm3 (five,000 to 10,000/mm3)
rationale: Clozapine can motive agranulocytosis, which may be fatal due to overwhelming
contamination. The nurse must perceive a WBC depend of much less than 3,000/mm³ as a
likely manifestation of agranulocytosis and have to withhold the medicine and notify the
company.
A nurse is making plans care for a consumer who has despair and has made frequent suicide
tries. Which of the following statements shows the customer has a reduced chance for suicide?
A. "I'm relieved now that my economic affairs are so as."
b. "it is easier to speak approximately my feelings now."
c. "all at once i have enough power to do anything I need"
d. "thank you for usually taking such appropriate care of me"
b. "it is less difficult to speak approximately my emotions now."
motive: when customers explicit their feelinds, this shows a high-quality remedy outcome.
All through a customer's initial interview in a mental health inpatient placing, a nurse identifies
that the customer is retaining eye contact and leaning ahead. Which of the subsequent
assumptions must the nurse make primarily based at the purchaser's nonverbal behaviors?
A. Purchaser is interested by what the nurse is pronouncing.
B. The purchaser is attempting to manipulate the nurse.
C. The purchaser is bodily interested in the nurse.
D. The patron is seeking acceptance by way of the nurse.
A. The consumer is interested in what the nurse is saying.
Cause: the clients posture and eye touch display an hobby inside the interview and what the
nurse is saying.
, The customer is seeking reputation by the nurse.
A. Promote the use of tune to compete with the consumer's auditory hallucinations.
B. Inform the patron that the auditory hallucinations are not actual.
C.Avoid asking the customer if they may be experiencing auditory hallucinations.
D.Instruct the client on using voice reputation concerning the auditory hallucinations.
A. Promote the use of tune to compete with the consumer's auditory hallucinations.
Rationale: Competing truth-primarily based stimulation consisting of using tune or tv during
auditory hallucinations can help in limiting the effect the hallucinations have on the client's stress
stage.
A nurse is being concerned for a consumer who has impaired cognition.
A nurse is updating the patron's plan of care. For every of the following capability nursing
interventions, click on to specify if the capacity intervention is predicted, nonessential, or
contraindicated for the customer.
Show off 1
Medical History
Day 1, 0800:
Client treated for UTI eight months ago.
Day three, 0830:
Client fell getting away from bed to visit the bathroom remaining night. Client sustained bruise to
the left knee; no in addition injuries referred to.
Exhibit 2
Vital Signs
Day 1, 0800:
Temperature 36.9° C (98.Four° F)Heart rate 92/minRespiratory price 26/minBlood pressure
132/eighty mm Hg
Day 3, 0830:
Temperature 37.3° C (ninety nine.1° F)Heart fee 106/minRespiratory price 32/minBlood strain
144/86 mm Hg
Exhibit three
Nurses' Notes
Day 1, 0800:
Client is able to assist with self-care. Client is effortlessly startled through sudden adjustments
and loud noises.
Day 3, 0830:
Client has wandered into oth
A college nurse is assessing a school-age child who skilled the worrying loss of a determine 8
months in the past. Which of the subsequent findings have to the nurse perceive as an
indication that the kid is experiencing submit-worrying strain disorder (PTSD)?
A. Clinging behaviors directed toward a instructor
b. Growth time spent drowsing
c. Intense awareness on faculty work
d. Lack of hobby in an upcoming excursion
D. Lack of hobby in an upcoming vacation
rationale: the child who has PTSD can have terrible moods an issue remembering aspects of
the traumatic occasion. The child also have loss hobby or lack of participation in extensive
activities and occasion along with vacations.
A nurse is worrying for a collection of customers. Which of the subsequent findings have to the
nurse record?
A. A consumer who is taking clozapine and has a WBC matter of 7,500/mm3 (5,000 to
10,000/mm3)
b. A purchaser who's taking lamotrigine and has advanced a rash.
C. A purchaser who is taking valproate and has a platelet be counted of two hundred,000/mm3
(one hundred fifty,000 to 400,000/mm3)
d. A consumer who's taking lithium and has multiplied thirst
b. A consumer who is taking lamotrigine and has advanced a rash.
Purpose: lamotrigine is an anticonvulsant medicinal drug this is used as a temper stabilizer. The
nurse ought to become aware of that a rash is a potentially life-threatening unfavorable effect of
the drugs and report this locating straight away.
A nurse is caring for a male client who has schizophrenia and is taking clozapine. Which of the
subsequent customer findings must the nurse perceive as a contraindication for receiving
clozapine?
A. WBC matter 2,500/mm3 (five,000 to 10,000/mm3)
,b. Hgb 11.Five mg/dL (14 to 18 g/dL)
c. Alogia
d. Client reviews having a dry mouth
a. WBC be counted 2,500/mm3 (five,000 to 10,000/mm3)
rationale: Clozapine can motive agranulocytosis, which may be fatal due to overwhelming
contamination. The nurse must perceive a WBC depend of much less than 3,000/mm³ as a
likely manifestation of agranulocytosis and have to withhold the medicine and notify the
company.
A nurse is making plans care for a consumer who has despair and has made frequent suicide
tries. Which of the following statements shows the customer has a reduced chance for suicide?
A. "I'm relieved now that my economic affairs are so as."
b. "it is easier to speak approximately my feelings now."
c. "all at once i have enough power to do anything I need"
d. "thank you for usually taking such appropriate care of me"
b. "it is less difficult to speak approximately my emotions now."
motive: when customers explicit their feelinds, this shows a high-quality remedy outcome.
All through a customer's initial interview in a mental health inpatient placing, a nurse identifies
that the customer is retaining eye contact and leaning ahead. Which of the subsequent
assumptions must the nurse make primarily based at the purchaser's nonverbal behaviors?
A. Purchaser is interested by what the nurse is pronouncing.
B. The purchaser is attempting to manipulate the nurse.
C. The purchaser is bodily interested in the nurse.
D. The patron is seeking acceptance by way of the nurse.
A. The consumer is interested in what the nurse is saying.
Cause: the clients posture and eye touch display an hobby inside the interview and what the
nurse is saying.
, The customer is seeking reputation by the nurse.
A. Promote the use of tune to compete with the consumer's auditory hallucinations.
B. Inform the patron that the auditory hallucinations are not actual.
C.Avoid asking the customer if they may be experiencing auditory hallucinations.
D.Instruct the client on using voice reputation concerning the auditory hallucinations.
A. Promote the use of tune to compete with the consumer's auditory hallucinations.
Rationale: Competing truth-primarily based stimulation consisting of using tune or tv during
auditory hallucinations can help in limiting the effect the hallucinations have on the client's stress
stage.
A nurse is being concerned for a consumer who has impaired cognition.
A nurse is updating the patron's plan of care. For every of the following capability nursing
interventions, click on to specify if the capacity intervention is predicted, nonessential, or
contraindicated for the customer.
Show off 1
Medical History
Day 1, 0800:
Client treated for UTI eight months ago.
Day three, 0830:
Client fell getting away from bed to visit the bathroom remaining night. Client sustained bruise to
the left knee; no in addition injuries referred to.
Exhibit 2
Vital Signs
Day 1, 0800:
Temperature 36.9° C (98.Four° F)Heart rate 92/minRespiratory price 26/minBlood pressure
132/eighty mm Hg
Day 3, 0830:
Temperature 37.3° C (ninety nine.1° F)Heart fee 106/minRespiratory price 32/minBlood strain
144/86 mm Hg
Exhibit three
Nurses' Notes
Day 1, 0800:
Client is able to assist with self-care. Client is effortlessly startled through sudden adjustments
and loud noises.
Day 3, 0830:
Client has wandered into oth
