Exam (elaborations) Mental Health ATI - Assessment A 2022 60 Questions & Answers

Mental Health ATI - Assessment A 2022 60 Questions & Answers 1. A nurse in mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first? - Accompany the client to a quiet room. (Greatest risk for this client is injury due to severe anxiety. Therefore, first action nurse should take is to stay with client and bring him to a room with minimal stimuli.) 2. A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with PTSD? (Select all that apply) - Distressing dreams Difficulty concentrating Exaggerated startle response 3. A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider? - Shuffling gait. (Clinical findings of pseudoparkinsonism such as shuffling gait may occur 5hr - 30 days after beginning treatment. The client should notify the provider who might prescribe an anti parkinsonism agent.) 4. A home health nurse is assessing an older adult client who lives alone. Which of the following findings should indicate to the nurse that the client is experiencing delirium? - Sudden onset. (Clients usually develop delirium suddenly over hours to days.) 5. A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor? - Urinary retention. 6. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. Client's morning lithium level is 1.5 mEq/L. Which of the following additional laboratory data has the highest priority? a) Serum erythrocyte sedimentation rate 18 mm/hr b) Hemoglobin 15 g/dL c) serum T4 5 mcg/dL d) Serum sodium 125 mEq/L - Serum sodium 125 mEq/L (In the presence of low sodium levels, renal excretion of lithium is reduced and client is at risk for lithium toxicity.Therefore, this finding is highest priority because it places client at greatest risk for injury.) 7. A nurse is caring for a client who has a history of substance use and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? - Do not administer the lorazepam. (Clients who are involuntarily admitted retain the right to refuse treatment.) 8. A nurse is developing a discharge plan for a client who has a history of gambling dependency and includes participation in support group. The nurse should tell the client that which of the following is the purpose of attending a support group? - Provide assurance that others have a similar problem. (Participating in a support group with other individuals who have similar problems will show the client that he is not the only one with this problem. The client can learn alternative ways to solve problems that other members of the group have also experienced.) 9. A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy (ECT). Provider needs to explain procedure to client in order to obtain informed consent. Which of the following actions should the nurse take? - Request a professional interpreter to translate. 10. Nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the eaching? - Right to treatment ensures individualized care. 11. Nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent? - A 35-year-old who has major depressive disorder. 12. A nurse is caring for client whose child recently died in a motor vehicle crash and states, "I just want to join him." Which of the following is the nurse's priority response? - "Are you thinking about harming yourself?" (Greatest risk is self-injury; priority is therefore to ask client if she has plans for self-harm) 13. A nurse is assessing a client in the ED. Client appears agitated, his blood pressure is 152/94 mm Hg, his HR is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances? - Cocane (cocaine intoxication causes tachycardia, elevated BP, dilated pupils, and agitation. These physiological findings suggest cocaine intoxication).14. A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor? - Blood glucose (risperidone can cause diabetes mellitus to develop; therefore, nurse should plan to monitor client's blood glucose level when taking this medication) 15. Nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest? - Roasted chicken. (contains little to no tyramine and is an appropriate menu choice for client who is taking tranylcypromine, an MAOI) 16. A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider? - Coarse hand tremor. (Coarse hand tremor can indicate toxicity and the client should report this finding to the provider immediately)