VATI PN MENTAL HEALTH ASSESSMENT EXAM QUESTIONS WITH
CORRECT DETAILED ANSWERS || 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 short-term 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.
CORRECT DETAILED ANSWERS || 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 short-term 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.
