Mental Health Practice Part B with NGN Actual Exam Questions An Well Elaborated Answers.

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? - correct answer Easily distracted Extreme distractibility is a hallmark manifestation of delirium. A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? - correct answer "I'll stay with you just in case you want to talk." This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings. 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? - correct answer A 35-year-old client who has major depressive disorder. A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - correct answer "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? - correct answer Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever. A nurse is planning care for a client who has made 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? - correct answer Nonmaleficence 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. A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? - correct answer The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program. A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? - correct answer Renew the prescription for the client every 4 hr. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr. 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? - correct answer Inform the client that this admission is confidential. According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship. A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdiscplinary services for the client at home? - correct answer Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy. A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? - correct answer Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care. A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? - correct answer "It is important for our child to have regular dental checkups." For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa. A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? - correct answer Greater risk of attempting suicide as affect and energy improve