ATI Mental Health Assessment B 2019

RN is assessing a family's dynamics during a counseling session. The RN should recognize which of the following findings as an indication of a boundary issue? - Older children who are responsible for their younger siblings -Ex. enmeshed boundaries - there are no distinctions between the roles of the family members. RN is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, what action should the RN take first? - Inform the client that this admission is confidential -The RN should first inform the client about confidentiality during the orientation phase of the nurse-client relationship. RN is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. What assessment findings support the RN's suspicion of delirium? - Easily distracted -extreme distractibility is a hallmark manifestations of delirium RN caring for an older adult client who is experiencing delirium. What interventions should the nurse include in the client's plan of care? - Permit the client to perform daily rituals to decrease anxiety. -The RN should provide the client with delirium a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals. RN is planning care for a client who has bipolar disorder and is experiencing mania. What interventions should the RN include in the plan of care? - Offer the client high-calorie finger foods frequently -The RN should frequently offer the client high-calorie foods that can be eaten on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration. RN is teaching a partner of a client who has bipolar disorder how to identify manifestations of acute mania. What findings should the client's partner report to the provider? - Inability to sleep -During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore the RN should instruct the partner to report this finding. RN is caring for a client who is experiencing a panic attack. What actions should the RN take? - Assist the client with deep-breathing exercises -Relaxation techniques help defuse manifestations of anxiety RN is talking with a group of parents who have recently experienced the death of a child. What actions should the RN take? - Suggest forming a weekly support group for parents who have experienced the death of a child. -support groups are a positive resource in the process of recovery for parents following the death of a child. RN is teaching a group of newly licensed nurses about the use of mechanical restraints. What information should the nurse include in the teaching? - Apply restraints when other means of managing the client's behavior have failed -According to the patient self-determination act, clients have a right to be free from restraints or seclusion unless the safety of the clients or others is at risk. De- Escalation methods for controlling behavior should be attempted prior to initiating restraints. RN is assessing a client who is experiencing opioid withdrawal. What manifestations should the nurse expect? - Rhinorrhea -Rn should expect rhinorrhea and flu-like manifestations like yawning, sneezing, and abdominal pain RN is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the groups time. What interventions should the nurse implement? - Ask group members to discuss their feelings about the client's monopolizing behavior. -This intervention will validate other members' feelings toward the client who is dominating the meeting. It should also encourage group problem-solving. RN is assessing a client who has bulimia nervosa. The RN should expect what findings? - Tooth erosion -Client with bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting. RN in a community health center is working with a group of clients who have PTSD. What interventions should the nurse include to reduce anxiety among the group members? - Guided imagery -involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have PTSD. RN is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. What referrals should the nurse initiate? - Occupational therapy Meal Delivery Services Physical Therapy Home Health services RN at a provider's office is interviewing an older adult client. What actions should the RN plan to take? - Use a screening tool to evaluate the client for depression -Depression can be underdiagnosed among older adult clients. There are several risk factors from the client's data including having Alzheimer's disease, anxiety, and the loss of a loved one. S/S can be nonspecific including weight loss, decreased energy levels, and difficulty sleeping RN 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. What ethical principle should the nurse apply in this situation? - Nonmaleficence -to do no harm. the RN is requesting transfer of this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit. RN is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. What behaviors is the priority for the nurse to report to the tx team? - Giving away possessions -indicates that this client is at greatest risk for suicide. Therefore this is the priority to report. RN is assessing a client for risk factors for the development of depression. The RN should identify what factors place the client at an increased risk for depression? - The client has COPD -Clients with a chronic illness are at an increased risk for the development of depression RN 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." What therapeutic responses demonstrates summarization? - "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." -summarizing the key points of the discussion RN is caring for 4 clients in the ED. The RN should identify what client can give informed consent? - A 35-year-old client who has MDD -client with MDD is capable of making health care decisions unless the client is determined to be legally incompetent RN in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. What manifestations should the nurse include? - Experiences feelings of isolation -The RN should expect clients who have PTSD to feel estranged and detached from others RN is assisting a client who has a terminal illness adjust to progressive loss of independence. what statements by the client indicate acceptance of her illness? - "I am going to order a wheelchair for when I'm unable to walk." -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. RN observes a client on a mental health unit pushing on the locked unit door. What statements should the nurse make? - "It appears as though you would like to open the door" -therapeutic technique of making observations. The technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior. RN is planning prevention strategies for partner violence in the community. What strategies should the nurse include as a method of secondary prevention? - Establish screening programs to identify at-risk clients -This is an ex. of secondary prevention. screening programs can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs. RN is admitting a client who has MDD and a new prescription for tranylcypromine. What OTC med should alert the nurse to a potential A/rxn? - Phenylephrine -tranylcypromine, an MAOI antidepressant, should NOT take any OTC meds for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe HTN. RN is planning discharge teaching for a client who has severe schizoaffective disorder. The RN should identify what tx options can offer interdisciplinary services for the client at home? - Assertive Community Tx -ACT provides comprehensive, community-based services to clients who have severe mental illness based upon individual needs. Services are available in any setting including the clients home, 24hr per day and provide crisis intervention, med services, and advocacy RN in ED is caring for a female adolescent who has a dx of bulimia nervosa and had a fainting episode during a ballet performance. What statement by the parent acknowledges the client's dx? - "She won't let me take the trash from her room. I'm concerned about what she has in there." -The client might be binge-eating and attempting to hide food containers, which is common behavior among clients who have bulimia nervosa. The statement indicates awareness.