ATI Mental Health Practice B 2022

ATI Mental Health Practice B 2022 A nurse is reinforcing teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that eating foods high in tyramine can cause which of the following adverse reactions with this medication? A. Hypertensive crisis B. Serotonin syndrome C. Hearing loss D. Urinary incontinence - Answer- A. Hypertensive crisis RAT: Tyramine can cause severe hypertension in clients who are taking phenelzine, a monoamine oxidase inhibitor. Manifestations include palpitations, stiff neck, headache, nausea, vomiting, and elevated temperature. A nurse is contributing to the plan of care for a client who has antisocial personality disorder. Which of the following short-term goals should the nurse recommend be included in the plan? The client will participate in assertiveness training. The client will discuss feelings that cause hostility. The client will describe an activity they found enjoyable. The client will dress in a manner appropriate for the setting and temperature. - Answer- The client will discuss feelings that cause hostility. RAT: Clients who have antisocial personality disorder are frequently aggressive and are at risk for injuring themselves or others. A short-term goal for these clients should be to discuss feelings that precipitate aggression or hostility. The nurse is assisting with an admission have a client who has eating disorder. During data collection, which is the following to the nurse identify as manifestations of bulimia nervosa? SOA A. Tooth erosion B. Hand calluses C. Lanugo D. Amenorrhea E. Hypokalemia - Answer- A. Tooth erosion B. Hand calluses E. Hypokalemia RAT: Tooth erosion is a manifestation of bulimia nervosa that results from selfinduced vomiting. Hand calluses are a manifestation of bulimia nervosa that results from self-induced vomiting. Lanugo is a manifestation of anorexia nervosa that results from starvation. Amenorrhea is a manifestation of anorexia nervosa that results from extreme weight loss. Hypokalemia is a manifestation of bulimia nervosa that results from volume depletion due to self-induced vomiting or excessive diuretic and laxative use. A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? A. Potassium 4.0 mEq/L B. Lithium 0.9 mEq/L C. BUN 12 mg/dL D. Sodium 132 mEq/L - Answer- D. Sodium 132 mEq/L RAT: The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider. A nurse in a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? A. Weigh the client at night prior to bedtime. B. Offer liquid supplements to the client. C. Encourage the client to gain 2.3 kg (5 lb) per week. D. Observe the client for up to 30 min after meals. - Answer- B. Offer liquid supplements to the client. RAT: The nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when they are first admitted. The nurse should observe the client for at least 1 hr after meals to prevent the client from throwing away, hiding, or purging food. A nurse is contributing to plan of care for a school-age child who has attention deficit hyperactivity disorder. Which of the following interventions should the nurse recommend? A. Avoid the use of humor when managing the child's disruptive behaviors. B. Instruct the child to apologize for behavior that negatively affects others. C. Maintain a scheduled plan of activities regardless of the child's behavior. D. Administer methylphenidate PRN when the child exhibits disruptive behavior. - Answer- B. Instruct the child to apologize for behavior that negatively affects others. RAT: The nurse should recommend performing simple techniques to manage the child's behavior, including making amends. This technique includes apologizing to others when the client's behavior has a negative effect. A nurse is reviewing laboratory values for a client who has anorexia nervosa. Which of the following results should the nurse expect? A. Potassium 3 mEq/L B. Phosphorus 3.5 mg/dL C. Magnesium 1.8 mEq/L D. Cholesterol 165 mg/dL - Answer- A. Potassium 3 mEq/L RAT: The nurse should expect a client who has anorexia nervosa to have hypokalemia, which is indicated by a decreased potassium level. This value is below the expected reference range of 3.5 to 5 mEq/L. A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Decreased heart rate C. Slurred speech D. Rhinorrhea - Answer- A. Elevated blood pressure RAT: Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to 12 hr of cessation of alcohol ingestion. A nurse is caring for a client who recently lost their child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? A. "Are there times when you feel more upset than others?" B. "Have you had any thoughts of harming yourself?" C. "What type of support system do you currently have?" D. "During difficult times in the past, what did you do to cope?" - Answer- B. "Have you had any thoughts of harming yourself?" RAT: The greatest risk to this client is self-injury due to suicide. Asking whether or not the client has plans to hurt themselves is the most important question for the nurse to ask at this time because a positive response can alert the nurse to the need for suicide precautions and intervention. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider? A. Fasting blood glucose B. Temperature C. WBC count D. Heart rate - Answer- C. WBC count RAT: The nurse should identify that a WBC count of 3,000/mm3 is below the expected reference range of 5,000 to 10,000/mm3. The nurse should identify that clozapine can cause agranulocytosis, a decrease in white blood cells, which can be life threatening. Therefore, the nurse should withhold the client's medications and notify the provider of this finding. A nurse is collecting data from a client whose home was destroyed by a fire. Which of the following responses should the nurse make first? A. "Are you experiencing feelings of hopelessness?" B. "Is there someone I can call for you?" C. "It might be helpful for you to attend a support group." D. "Now is a good time for you to use relaxation breathing." - Answer- A. "Are you experiencing feelings of hopelessness?" RAT: When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe. The nurse should collect data about the client's feelings to determine if the client is having feelings of hopelessness or suicidal ideations. A nurse is collecting data from a client who is taking valproic acid for the treatment of a bipolar disorder. Which of the following findings is the priority to the provider? A. Dizziness B. Weight gain C. Constipation D. Yellow sclerae - Answer- D. Yellow sclerae RAT: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is yellow sclerae because of the risk for hepatotoxicity. A nurse is reinforcing teaching about food that contains tyramine with a client who has a prescription for phenelzine. Which of the following foods should the nurse instruct the client to void? A. Fried chicken B. Oranges C. Smoked sausage D. Lentils - Answer- C. Smoked sausage RAT: Smoked sausages are high in tyramine. Clients who are prescribed monoamine oxidase inhibitors (MAOIs) should avoid food that contain tyramine because consuming them can cause a hypertensive crisis. A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and their own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? A. Discuss information about the dilemma with the client's provider. B. Determine the benefits and consequences of respecting the client's medical decisions. C. Reflect on the effect of ethical theories on the nurse's personal values. D. Develop a plan that balances both the nurse's values and the client's medical decisions. - Answer- B. Determine the benefits and consequences of respecting the client's medical decisions. RAT: After the nurse collects the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the client's medical decisions as the next step in the ethical decision-making model. A nurse is caring for four clients who are displaying the use of defense mechanisms. Which of the following clients should the nurse identify as using maladaptive defense mechanism? A. A client who has multiple sclerosis stops taking their medication and says their diagnosis is wrong. B. An adolescent client who has difficulty with reading becomes a star athlete. C. A client admires a high school principal who separated two students who were having a fight. D. A client who has a gambling disorder volunteers in a head start program. - Answer- A. A client who has multiple sclerosis stops taking their medication and says their diagnosis is wrong. RAT: Suppression is the blocking of thoughts or feelings that a client finds unacceptable. Denying the presence of an illness is a maladaptive use of a defense mechanism. A nurse is caring for a client who is scheduled for electro conclusive therapy ECT. Which of the following actions should the nurse take prior to the procedure? A. Keep the client in a side-lying position. B. Administer morphine IV. C. Prepare the client for intubation. D. Administer atropine sulfate IM. - Answer- D. Administer atropine sulfate IM. RAT: In preparation for ECT, the nurse should administer atropine sulfate IM 30 min prior to the procedure. This will decrease secretions in order to prevent aspiration that can be caused by the vagal stimulation induced by ECT. A nurse is talking with a client who has borderline personality disorder. The client states they think that the other nurses avoid them, but they are afraid to share this thought with the other staff. Which of the following actions should the nurse take? A. Encourage the use of transference in the nurse-client relationship. B. Offer to talk to the staff until the client gains an increased level of trust. C. Encourage the client's verbalization of feeling and perceptions. D. Ask the client why they think the staff is avoiding them. - Answer- C. Encourage the client's verbalization of feeling and perceptions. RAT: The nurse should encourage the client to verbalize their feelings, perceptions, and fears. Discussing these dynamics can help increase the client's comfort in expressing concerns directly to other members of staff. A nurse is collecting data from a client who has a history of cocaine use. Which of the following findings is an indication that the client is experiencing cocaine toxicity? A. Hypothermia B. Piloerection C. Somnolence D. Seizures - Answer- D. Seizures RAT: The nurse should expect a client who is experiencing cocaine toxicity to experience seizures. Other findings include severe anxiety, hallucinations, and paranoid thoughts. A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The nurse should identify that which of the following findings indicates a potential need for a PRN dose of benztropine? A. Sore throat B. Increased mental confusion C. Urinary retention D. Shuffling gait - Answer- D. Shuffling gait RAT: The nurse should identify that a shuffling gait can be indicative of the presence of pseudoparkinsonism, which can be treated with a PRN dose of benztropine. A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as predisposing factor for delirium? A. Hepatic failure B. Chronic alcohol use C. Hypertension D. Fluid volume overload - Answer- A. Hepatic failure RAT: Hepatic failure can be a predisposing factor for the development of delirium. Other potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke. A nurse is caring for a client who is experiencing opioid withdrawal. Which of he following medications should the nurse expect to administer? A. Naltrexone B. Bupropion C. Varenicline D. Phenobarbital - Answer- A. Naltrexone RAT: The nurse should expect to administer naltrexone, an opioid antagonist, to a client who is experiencing opioid withdrawal. A nurse is caring for a client who has depressive disorder and declines electro conclusive therapy (ECT) despite the provider's recommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client's decision? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice - Answer- A. Autonomy RAT: The nurse is demonstrating the principle of autonomy by respecting and supporting the client's right to make decisions about their treatment. A nurse is reinforcing teaching with a client has OCD and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse take to demonstrate modeling as a behavioral intervention strategy? A. Setting a time limit between episodes of hand hygiene B. Reminding the client to shout "stop" each time they have an urge to perform hand hygiene C. Demonstrating performing hand hygiene at appropriate times D. Instructing the client to practice muscle relaxation when they have the urge to perform hand hygiene - Answer- C. Demonstrating performing hand hygiene at appropriate times RAT: This action is an example of modeling, which is a strategy that allows the client to see another person perform the expected behavior. A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? A. A client who has anergia B. A client who demonstrates blunted affect C. A client who demonstrates concrete thinking D. A client who is experiencing command hallucinations - Answer- D. A client who is experiencing command hallucinations RAT: Because command hallucinations are a risk factor for violence, the greatest risk to this client is injury to self or others. Therefore, the nurse should see this client first. A nurse is caring for a client who is undergoing behavioral therapy for PTSD. The nurse should identify that which of the following findings indicates an improvement in the client's condition? A. The client reports about techniques they use to promote sleep. B. The client shows limited emotion when discussing witnessing a traumatic event. C. The client states that they no longer feel like they can trust their partner. D. The client avoids situations that might trigger memories of past trauma. - AnswerA. The client reports about techniques they use to promote sleep. RAT: Clients who have PTSD frequently experience disrupted sleep. Therefore, reporting about techniques they use to promote sleep demonstrates that the client's condition has improved. A nurse in an inpatient mental health unit is supervising a group of clients in the unit's dayroom. The nurse fails to respond to the escalating, aggressive behavior of a client who eventually become violent and injures another client. For which of the following is the nurse liable? A. Battery B. Nonmaleficence C. Negligence D. Boundary violation - Answer- C. Negligence RAT: The nurse is liable for negligence by failing to respond to the client's escalating, aggressive behavior and prevent harm to others........