VATI PN Mental Health Assessment
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? - ANSIrregular 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? -
ANSCheck 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? -
ANS"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? - ANSOffer
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? - ANSAbdominal 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? - ANSExplain 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? - ANSMove 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.) - ANSStay 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 that the child fell out of a tree. The child is guarding their right arm. For
which of the following findings should the nurse suspect physical maltreatment? - ANSAn x-ray
of the right arm indicates a spiral fracture.
The nurse should identify that an x-ray indicating a fracture can be an expected finding for a
child who fell out of a tree. However, a spiral fracture is caused by twisting of the extremity and
can be an indication of physical maltreatment. The nurse should report the findings to the
registered nurse.
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? - ANSIrregular 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? -
ANSCheck 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? -
ANS"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? - ANSOffer
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? - ANSAbdominal 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? - ANSExplain 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? - ANSMove 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.) - ANSStay 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 that the child fell out of a tree. The child is guarding their right arm. For
which of the following findings should the nurse suspect physical maltreatment? - ANSAn x-ray
of the right arm indicates a spiral fracture.
The nurse should identify that an x-ray indicating a fracture can be an expected finding for a
child who fell out of a tree. However, a spiral fracture is caused by twisting of the extremity and
can be an indication of physical maltreatment. The nurse should report the findings to the
registered nurse.
