RN MENTAL HEALTH PRACTICE B 2016 ATI

RN MENTAL HEALTH PRACTICE B 2016 ATI 1. A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make a. "It is not uncommon to feel angry toward yourself or others Reason: Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss. 2. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching a. "Take this medication with food Reason: Lithium can cause GI distress and should be taken with food. Recommended sodium intake 1500mg/day. Recommended ml/day fluids. 3. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs a. A client who has severe Alzheimer's disease Reason: Alzheimer's clients are typically confused with memory difficulties, tend to wander and need ADL assistance. 4. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan a. Identify the client's trigger foods Reason: Nurse should identify trigger foods that initiate the client's binge and assist the client to understand his thoughts and behavior that relate to the food 5. A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse a. A family where one or both parents witnessed intimate partner violence in the home as children Reason: Parents who witnessed intimate partner violence as a child are more likely to become abusive. 6. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first a. Inform the client that her admission is confidential Reason: According to EBP, Nurse should inform client about confidentiality during orientation phase of nurse-client relationship 7. A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent a. A 35-year-old client who has major depressive disorder Reason; Client who has major depressive disorder is capable of making health care decisions unless determined legally incompetent 8. A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following a. Clang association Reason: Clang associations often rhymes or contains a string of words that can have the same beginning sound. 9. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching a. Language delay 10. A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take a. Ask the client what the voices are saying 11. A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make a. "Let's talk about what is upsetting you Reason: The nurse us acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling 12. A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first a. Discuss the importance of hair with the client Reason: anticipatory grieving begins with acknowledging the importance of the expected loss 13. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data a. Sodium level 125 mEq/l