Mental Health ATI - Assessment A Correct 100%

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? - ANSWER 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.) 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) - ANSWER Distressing dreams Difficulty concentrating Exaggerated startle response 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? - ANSWER 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.) 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? - ANSWER Sudden onset. (Clients usually develop delirium suddenly over hours to days.) A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor? - ANSWER Urinary retention. 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 - ANSWER 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.) 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