VATI PN Mental Health Assessment, Medical Surgery 2-
Theory , Unitek College Exam With Complete Questions
And Correct 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 recently experienced a traumatic event. The nurse should
identify that which of the following is an example of the client using repression as a defense
mechanism? - answer: The client reports not being able to remember anything about the
event.
The nurse should identify the use of repression as a defense mechanism when the client
reports not being able to remember anything about a traumatic event after it occurs.
Repression is the unconscious process of blocking unpleasant or traumatic memories to avoid
addressing the emotions associated with them.
A nurse is caring for a client who has schizophrenia. The client is refusing to participate in the
current group activity. Which of the following statements should the nurse make? - answer:
"You do not have to participate right now if you don't feel comfortable."
, Clients who have schizophrenia often have difficulty interacting with others. The nurse should
allow the client to observe the group until they feel comfortable participating. This response
by the nurse is therapeutic because it indicates acceptance of the client's feelings.
A nurse is caring for a client on a mental health unit and receives a call from the client's
sibling requesting information regarding the client's condition. The client has not listed
anyone on the release-of-information form. Which of the following actions should the nurse
take? - answer: Tell the caller that information cannot be released regarding their request.
The nurse must identify that the only individuals who have a right to a client's personal health
information are those directly involved in the client's care and any individuals the client lists
on the release-of-information form. Telling the caller that information cannot be released
regarding their request protects the confidentiality of the client.
A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of
the following findings should the nurse expect? - answer: Restlessness
Clients who have GAD can be irritable and restless. They tend to worry excessively, far more
than events or situations warrant.
A nurse is caring for a client who has Parkinson's disease. The client states, "Everything is
looking pretty grim for me." Which of the following is the priority action for the nurse to take?
- answer: Ask the client if they have a specific plan for suicide.
The nurse should recognize that having a plan for suicide indicates that the client is at greatest
risk for self-harm. Therefore, the priority action for the nurse is to determine if the client has
a specific plan for suicide.
A nurse is caring for a client who frequently displays manipulative behavior. Which of the
following actions should the nurse take? - answer: Establish consequences for the client's
actions.
Theory , Unitek College Exam With Complete Questions
And Correct 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 recently experienced a traumatic event. The nurse should
identify that which of the following is an example of the client using repression as a defense
mechanism? - answer: The client reports not being able to remember anything about the
event.
The nurse should identify the use of repression as a defense mechanism when the client
reports not being able to remember anything about a traumatic event after it occurs.
Repression is the unconscious process of blocking unpleasant or traumatic memories to avoid
addressing the emotions associated with them.
A nurse is caring for a client who has schizophrenia. The client is refusing to participate in the
current group activity. Which of the following statements should the nurse make? - answer:
"You do not have to participate right now if you don't feel comfortable."
, Clients who have schizophrenia often have difficulty interacting with others. The nurse should
allow the client to observe the group until they feel comfortable participating. This response
by the nurse is therapeutic because it indicates acceptance of the client's feelings.
A nurse is caring for a client on a mental health unit and receives a call from the client's
sibling requesting information regarding the client's condition. The client has not listed
anyone on the release-of-information form. Which of the following actions should the nurse
take? - answer: Tell the caller that information cannot be released regarding their request.
The nurse must identify that the only individuals who have a right to a client's personal health
information are those directly involved in the client's care and any individuals the client lists
on the release-of-information form. Telling the caller that information cannot be released
regarding their request protects the confidentiality of the client.
A nurse is collecting data from a client who has generalized anxiety disorder (GAD). Which of
the following findings should the nurse expect? - answer: Restlessness
Clients who have GAD can be irritable and restless. They tend to worry excessively, far more
than events or situations warrant.
A nurse is caring for a client who has Parkinson's disease. The client states, "Everything is
looking pretty grim for me." Which of the following is the priority action for the nurse to take?
- answer: Ask the client if they have a specific plan for suicide.
The nurse should recognize that having a plan for suicide indicates that the client is at greatest
risk for self-harm. Therefore, the priority action for the nurse is to determine if the client has
a specific plan for suicide.
A nurse is caring for a client who frequently displays manipulative behavior. Which of the
following actions should the nurse take? - answer: Establish consequences for the client's
actions.
