ATI Mental Health Exam B 2024

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 boundary issues? - Older children who are responsible for their younger siblings A nurse is performing an admission assessment and notices that the client appears withdrawal and fearful with nurse-client relationship, which of the following actions should the nurse take first? - Inform the client that her admission is confidential. R: 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 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 Nurs'e suspicion of delirium? - Easily distracted R: S/sx of delirium include confusion or being muddled. Disorientation - the person might not know where they are, what the date or time is, or not be able to recognise familiar people and objects. being unable to focus or concentrate - for example, being easily distracted or having rambling speech. 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 - Permit the client to perform daily rituals to decrease anxiety R: allowing them to do so will decrease frustration and anxiety 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? - Offer the client high-calorie finger foods frequently A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider - inability to sleep A nurse is caring for a client who is experiencing a panic attack. which of the following actions should the nurse take? - Assist the client with deep-breathing exercises A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? - Rhinorrhea Initial symptoms are anxiety, restlessness, aching back and legs, and cravings for more opioids. Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, RHINORRHEA, sweating, diarrhea, yawning, fever, and insomnia. 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? - Ask group members to discuss their feelings about this client's monopolizing behavior. The nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? - Tooth erosion 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? - Guided imagery Nurse is preparing to discharge an older adult client, who attempted suicide, to his home where he lives alone. Client also has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply) - Occupational therapy (to assist with ADLs)Meal delivery services (necessary due to difficulty performing ADLs)Physical therapy (to assess mobility needs and assist with ADLs)Home health services (provide nursing assessment of client's physical and mental status, as well as assistance with ADLs A nurse at a providers office is interviewing an older adult client. Which of the following actions should the nurse plan to take? - Ask the provider to decrease the dosage of the client's blood pressure medication 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 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? - Nonmaleficence