ATI Mental Health Final Exam

A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should the nurse plan to take? a)Restrict participation in group therapy sessions b)Establish consequences for self-mutilation c)Maintain close observation d) Provide an unstructered environment - c)Maintain close observation Clients who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What action should the nurse take? - Administer the medication at bedtime. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." What response should the nurse make? - "That must be very frightening." The nurse should respond to the client's delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship.A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect? - Confusion. The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are expected findings of this disorder. A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which manifestations is a common adverse effect of this medication? - Dizziness. The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined. A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. What finding should the nurse question the provider's prescription? - Hypotension. The nurse should question the provider's prescription for a benzodiazepine for a client who has hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac arrest. A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the priority for the nurse to report to the provider? - Elevated blood pressure.