PN VATI MENTAL HEALTH 2024 ACTUAL EXAM TEST BANK
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+.
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? - ANSWER-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? - ANSWER-
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? - ANSWER-"Your father
might experience shortterm 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? - ANSWER-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? - ANSWER-
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? - ANSWER-
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? - ANSWER-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.) -
ANSWER-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
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+.
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? - ANSWER-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? - ANSWER-
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? - ANSWER-"Your father
might experience shortterm 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? - ANSWER-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? - ANSWER-
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? - ANSWER-
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? - ANSWER-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.) -
ANSWER-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
