ATI RN Mental Health Online Practice 2019 B ALL 100% CORRECT AID GRADE A+

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issues? A. An adolescent family member who questions parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household Correct: C - This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members. A - incorrect - An adolescent who questions parental authority is demonstrating appropriate behaviors for developmental age B - incorrect - This scenario occurs in many households, not indication of boundary issue D. This is an example of a blended family, not indication of boundary issue A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse=client relationship, which of the following actions should the nurse take first? A. Inform the client that this admission is confidential B. Introduce the client to other clients in the day room C. Assist the client in facilitating behavioral change D. Determine coping strategies that the client used in the past A - CORRECt - According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship. B - Incorrect The nurse should introduce the client to other clients in the day room to help the client interact with others during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a different action first. C. INCORRECT The nurse should assist the client with behavioral change during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a different action first. D. Incorrect The nurse should determine what coping strategies the client used in the past during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a different action first. A nurse is performing a cognitive assessment to distinguish delirium form dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted D - CORRECT - Extreme distractibility is a hallmark manifestation of delirium. A - INCORRECT Delirium has an acute onset. Dementia is a slow, progressive decline. B. INCORRECT Aphasia is a manifestation of dementia C. INCORRECT Confabulation is a manifestation of dementia. A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? A. Offer the client various choices for meal selection B. Assign different nursing personnel for each shift C. Permit the client to perform daily rituals to decrease anxiety D. Maintain an environment that has low lighting C - CORRECT The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals. A- INCORRECT The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by limiting the choices the client is asked to make. B - The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing consistent nursing personnel. D - The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing a well-lit environment. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to participate in group therapy B. Instruct the client to avoid napping during the day C. Offer the client high-calorie finger foods frequently D. Decrease the client's daily fiber intake C - CORRECT The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration. A - INCORRECT The nurse should maintain a low-stimuli environment for a client who is experiencing mania. The nurse should dim the lights, decrease noise, and limit the number of people the client is around. B - The nurse should encourage the client to take frequent rest periods throughout the day. Clients experiencing mania are at risk of exhaustion that can be life threatening. D - The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients experiencing mania can experience dehydration and nutritional deficiencies from decreased intake, which can lead to constipation. A nurse is teaching the partner of a client who has bipolar disorder how to identify acute mania. Which of the following findings should the client's partner report to the provider? A. Obsessive attention to detail B. Inability to sleep C. Reports of fatigue D. Isolation from others B - CORRECT During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding A - INCORRECT During the manic phase of bipolar disorder, a client's behavior becomes disorganized and chaotic, which renders the client unable to focus on detail. C - INCORRECT Although the client who is experiencing acute mania might eventually become exhausted, there is a characteristic unawareness of fatigue during this phase. D - INCORRECT Clients who are in the manic phase of bipolar disorder often talk and joke incessantly and are highly interactive. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Orient the client to person, place and time B. Assist the client with deep-breathing exercises C. Calm the client by using therapeutic touch D. Have the client sit alone in a quiet room B - CORRECt Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. A - INCORRECT A client who is experiencing a panic attack is generally not disoriented. C - INCORRECT Therapeutic touch is not intended to de-escalate panic in a client who is anxious. D - INCORRECT It is recommended that the nurse stay with a client who is experiencing panic anxiety to ensure the client's safety. A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? A. Encourage the parents to avoid discussing the death with their other children to protect their feelings B. Recommend each parent grieve in private to avoid hindering each other's healing C. Suggest forming a weekly support group for parents who have experienced the death of a child D. Advise the parents to begin counseling if they are still grieving in a few months C - CORRECT Support groups are a positive resource in the process of recovery for parents following the death of a child. A - INCORRECT Siblings also experience feelings of intense grief and need to know it is acceptable for the family to grieve together. B - INCORRECT Although parents tend to grieve differently, it is important they share their grief and communicate their needs to decrease the likelihood of marital upset. D - INCORRECT The grief process varies for each individual. Setting an expected period for grief places the parents at risk for further problems if they feel they have not completed the grieving process in an acceptable amount of time. A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? A. Complete documentation about the client's status every house while they are in restraints B. Maintain the client in restraints for a minimum of 4 hr C. Apply restraints when other means of managing the client's behavior have failed D. Request that the provider assess the client within 8 hours of the application of restraints C - CORRECT According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints. A - INCORRECT The nurse should document the client's status, including behavior and vital signs, and address the client's physical and safety needs every 15 min. B - INCORRECT Restraints should be removed as soon as the client is able to follow instructions, control their behavior, and is no longer at risk for injuring themselves or others. The maximum amount of time an adult client should remain in restraints is 4 hr. D - INCORRECT The use of mechanical restraints requires a provider's prescription. In emergent cases, the prescription can be obtained after restraints have been applied. However, the provider must evaluate the client within 1 hr of the initiation of restraints. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? A. Sedation B. Rhinorrhea C. Bradycardia D. Hypothermia B - CORRECT The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain. A - INCORRECT The nurse should expect the client experiencing opioid withdrawal to have insomnia. C - INCORRECT The nurse should expect the client experiencing opioid withdrawal to have tachycardia. D - INCORRECT The nurse should expect the client experiencing opioid withdrawal to have hyperthermia A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? A. Tell the client to talk less or risk being removed from the meeting B. Ask group members to discuss their feelings about this client's monopolizing behavior C. End the group meeting and take the client aside to discuss the disruptive behavior D. Focus on other group members and ignore the client who is doing all the talking B - CORRECT This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving. A - INCORRECT Threatening the client is not a therapeutic intervention. C- INCORRECT This intervention is punitive to all members of the group, and it does not address the problem within the group setting. D - INCORRECT Ignoring the client does not address the behavior and is unlikely to solve the problem. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? A. Amenorrhea B. Lanugo C. Cold extremities D. Tooth erosion D - CORRECT A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting. A - INCORRECT A client who has anorexia nervosa is more likely to have amenorrhea resulting from low body weight. B - INCORRECT A client who has anorexia nervosa is more likely to have lanugo resulting from extreme malnutrition. C - INCORRECT A client who has anorexia nervosa is more likely to have cold extremities from extreme malnutrition. A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? A. Response prevention B. Guided Imagery C. Aversion therapy D. Light therapy B - CORRECT Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder. A - INCORRECT Response prevention is used in the treatment of compulsive behavior. C - INCORRECT Aversion therapy is a negative feedback method used to treat alcohol use disorder, violent behavior, and self-mutilation. D - INCORRECT Light therapy is used in the treatment of seasonal affective disorder, a type of depression A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate (Select all that apply) A. Occupational therapy B. Meal delivery services C. Speech-language pathologist D. Physical Therapy E. Home health services A - CORRECT An occupational therapist can assist the client to perform ADLs. B - CORRECT Meal delivery services are necessary due to the client's difficulty performing ADLs. D - CORRECT A physical therapist can assess the client's mobility needs and assist with ADLs. E - CORRECT Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs. C - INCORRECT There is no indication that the client needs a referral for a speech-language pathologist. This referral would be indicated if the client had difficulty swallowing. A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? A. Use a screening tool to evaluate the client for depression B. Ask the provider to decrease the dosage of the client's blood pressure medication C. Instruct the client to decrease intake of vitamin B12 D. Suggest the client go for a brisk walk 20 minutes just before bedtime A - CORRECT Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping. B - INCORRECT The client's blood pressure is within the expected reference range; the nurse should identify a systolic blood pressure of less than 90 mm Hg as hypotension. C - INCORRECT After age 50, the body's ability to absorb vitamins can decrease. Although the older adult client takes a multivitamin daily, the nurse should instruct the client to ensure adequate intake of vitamin B12 through fortified foods, such as whole-grain products. D - INCORRECT Exercise can help promote sleep; however, the nurse should instruct the client not to exercise just prior to bedtime because this might worsen insomnia. A nurse is planning care for a client who has mande repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? A. Non-maleficence B. Veracity C. Justice D. Autonomy A - CORRECT It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit. B - INCORRECT The nurse applies the ethical principle of veracity when being truthful with clients and others. C - INCORRECT The nurse applies the ethical principle of justice when treating all individuals equally and fairly. D - INCORRECT The nurse applies the ethical principle of autonomy by respecting a client's right to make independent choices. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team? A. calling family members B. Spending time alone C. Giving away possessions D. Excessive crying C - CORRECT Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team. A - INCORRECT The nurse should report that the client is calling family members to indicate that the client has a support system. However, another behavior is the priority. B - INCORRECT The nurse should report that the client is spending time alone to indicate the client is withdrawn from others. However, another behavior is the priority. D - INCORRECT The nurse should report that the client is crying excessively to indicate the client is showing signs of depression. However, another behavior is the priority A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? A. The client is married B. The client recently received a promotion at work C. The client has COPD D. The client is a male C - CORRECT The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression. A - INCORRECT The nurse should identify that clients who are single, not clients who are married, are at an increased risk for the development of depression. B - INCORRECT The nurse should identify that the presence of a negative life event, rather than a positive one, is a risk factor for the development of depression. D - INCORRECT The nurse should identify that clients who are female, not male, are at an increased risk for the development of depression. A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat" B. You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight C. You don't want to look at yourself because you think you are fat D. You and I can work together to overcome your fears of gaining weight B - CORRECT The nurse is using the therapeutic technique of summarizing to review the key points of the discussion. A - INCORRECT The nurse is using the therapeutic technique of focusing in this statement. C - INCORRECT The nurse is using the therapeutic technique of restating in this statement. D - INCORRECT The nurse is using the therapeutic technique of suggesting collaboration in this statement. A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? A. A 17 year old client who lives with friends B. 50 year old client who has a blood alcohol level of 80 mg/dL C. A 35 year old client who has major depressive disorder D. 65 year old client who just received a dose of morphine C - CORRECT A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent. A - INCORRECT Individuals younger than 18 years of age can only provide informed consent if they are married, pregnant, parents, or emancipated. B - INCORRECT A client who is intoxicated cannot legally give informed consent. D - INCORRECT A client who has just received morphine, an opioid analgesic, is functionally incompetent due to the medication's effect on the CNS. A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A. Repeatedly talks about the traumatic incident B. Sleeps excessively C. Experiences feelings of isolation D. Uses repetitive speech C - CORRECT The nurse should expect clients who have PTSD to feel estranged and detached from others. A - INCORRECT The nurse should identify avoidance of discussing the traumatic event as an expected manifestation of PTSD. B - INCORRECT The nurse should identify difficulty sleeping and hypervigilance as expected manifestations of PTSD. D - INCORRECT The nurse should identify that verbal aggression is a manifestation of PTSD; however, repetitive speech is not. A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness/ A. "I am going to order a wheelchair for when I'm unable to walk" B. "I am going to stop paying bills since I won't be around much longer" C. "I wish you would go take care of somebody who actually needs you." D. " I am sure I'm going to be able to continue to care for myself without help." A - CORRECT The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral response of acceptance. B - INCORRECT The client is verbalizing hopelessness and demonstrating the grieving stage of depression. This does not indicate acceptance. C - INCORRECT The client is expressing anger, which is a behavioral response to grief. This does not indicate acceptance. D - INCORRECT The client is expressing denial, which is a behavioral response to grief. This does not indicate acceptance. A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? CONTINUED...