Mental Health ATI Quiz 1 (Quiz 1)

5. 4. A nurse is assessing a client who is experiencing moderate level anxiety which of the following findings should the nurse expect? * Mark only one oval. The client has a heightened perceptual field. The client has difficulty concentrating. The client reports shortness of breath. The client reports a sense of impending doom. 6. 5. A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face, The client reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids" Which of the following responses should the nurse make? * Mark only one oval. "Aren't you worried about the safety of your children?" "Can you identify your behaviors that provoke your partner?" "The next time this occurs, what might you do to ensure your safety?" "You need to remove yourself and your children from the abusive situation." 7. 6. A nurse is performing a mental status assessment on an older adult client who has dementia which of the following questions should the nurse ask to assess the clients remote memory? * Mark only one oval. "What year did you graduate from high school?" "What is your favorite childhood memory?" "What did you have for supper yesterday?" "What is today's date?" 8. 7. A nurse is caring for a client who has dementia the client states to the nurse everyone wants to kill me which of the following responses should the nurse make? * Mark only one oval. "Tell me how everyone wants to hurt you." "You must feel very frightened to think someone wants to hurt you." "No one here wants to kill you." "Who in particular do you think wants to kill you?" 9. 8. A nurse is caring for a client whose adolescent child died in a motor-vehicle crash. The client is crying inconsolably. Which of the following actions should the nurse take? * Mark only one oval. Suggest that the client call the facility's chaplain. Provide a quiet place for the client to be alone. Stay with the client and allow the client to cry. Express sympathy for the client's loss. 10. 9. A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as the priority? * Mark only one oval. The client is confrontational with his parents. The client is getting Ds in his classes because he frequently skips school. The client states he smokes half a pack of cigarettes per day. The client gave his favorite possessions to friends. 11. 10. A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly asks personal questions about the nurse. Which of the following actions should the nurse take? * Mark only one oval. Explain that this time is designated to focus on the client. Answer the personal inquiry questions matter-of-factly. Tell the client that interest in someone besides himself is an indication of improvement. Request that personal questions be asked after the counseling session is over. 12. 11. A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide? * Mark only one oval. "Everything will be better soon." "Soon no one will have to worry about me." "There's no point in living any longer." "I want to donate my organs to help others." 13. 12. A nurse is caring for a client who has depression and started taking paroxetine one week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make? * Mark only one oval. "Why do you feel your family would be better off without you?" "Many people feel this way when they are depressed." "You sound upset. Are you thinking of hurting yourself?" "Your medication hasn't started working yet. Then you'll be feeling differently. " 14. 13. A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information? * Mark only one oval. "I am legally required to notify a client's employer about a substance use disorder." "If a client is involuntarily committed, I can discuss information with the client's next of kin." "I can discuss a client's treatment with others as long as they are employees of the facility." "I should keep information private even after a client dies." 15. 14. A nurse is caring for a client at a college mental counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms? * Mark only one oval. Projection Dissociation Undoing Compensation 16. 15. A nurse in an ED is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler's parents should cause the nurse to suspect child abuse? * Mark only one oval. "My child fell down the stairs." "My child was riding a bicycle and fell off." "My child slipped out of the high chair." "My child climbed up on a chair and it tipped over." 17. 16. A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, "Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms? * Mark only one oval. Denial Identification Introjection Sublimation 18. 17. A nurse is caring for a client who has schizophrenia. The client states, "My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions? * Mark only one oval. Somatic Reference Persecutory Grandiose 19. 18. A nurse is caring for a client who has alcohol use disorder and is receiving treatment for alcohol withdrawal. The client reports and tremors 12 hr after admission. Which of the following statements should the nurse make? * Mark only one oval. "The tremors are permanent due to nerve damage caused by chronic alcohol use." "The tremors will persist for a few days as you are withdrawing from alcohol." "Try not to worry about the tremors. Everyone has these during alcohol withdrawal." "These tremors are an indication of seizures that are associated with alcohol withdrawal." 20. 19. A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority? * Mark only one oval. "I hate being so helpless. I can't even manage my own finances anymore." "At group therapy today I wanted to leave. I didn't feeling like being with other people." "I have it all figured out. Everything is going to be okay now." "I don't feel like showering. I'd rather just stay in bed today." 21. 20. A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy? * Mark only one oval. The client will gain increased self-esteem. The client will maintain orientation to place and time. The client will independently perform ADLs. The client will achieve optimal sensory stimulation. 22. 21. A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase? * Mark only one oval. Identify the client's perception of the reason for therapy. Ask the client to provide a detailed description of the hallucinations. Assist the client with the development of problem-solving skills. Explore the client's relationship with family members. 23. 22. A nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the client. The nurse should recognize that she is demonstrating which of the following behaviors? * Mark only one oval. Suppression Countertransference Transference Assertiveness