ATI RN Mental Health Online Practice 2019 A

1. A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? - A client was administered one-half of the prescribed dose of medication an incident report is a recording of any occurrence that does not meet the standard of care. the nurse should report medication errors using the facility's incident or occurrence form 2. a nurse is caring for a group of clients. Which of the following findings is the nurse required to report? - A client who has borderline personality disorder threatened to harm their roommate s/s of BPD include interpersonal relationships accompanied by threats and other-directed violence. while it is important for the nurse to maintain the pts confidentiality on occasions when another individuals like might be in danger, the nurse is required by law to report it to authorities 3. A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? - The client will refrain from self-mutilation the greatest risk to the pt is injury to self and others. therefore, the priority goal is for the pt to refrain from self-mutilation 4. a nurse is discussing the home care of a client who has advanced Alzheimer's disease with he client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommended to the caregiver? - Respite care respite care programs allow the pt to stay ina nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves 5. A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? - Talk with the client about activities they enjoyed with their partner talking about positive experiences can help distract the pt from their disorientation 6. A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? - Clang association the nurse should document that the pts speech uses clang associations which often rhyme or contain a string of words that can have a similar sound 7. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? - Anhedonia neg symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than pos symptoms. these symptoms develop over time. examples of neg symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities and thought blocking 8. A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? - Change the dressing of a client who has borderline personality disorder and superficial self-inflicted wounds a pt who has borderline personality disorder is at risk for self-mutilation such as cutting, self-inflicted wounds, scratching or picking at wounds. it is within the LPNs scope of practice to change the dressing cleanse the wound, and collect data regarding the healing of the wound 9. A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? - Aggression toward animals the nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder 10. A nurse in a mental health clinic is planning car for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? - Instruct the client to avoid driving during initial therapy the greatest risk to the pt is injury resulting from drowsiness or dizziness. therefore the nurses priority intervention is to instruct the pt to avoid activities that require mental alertness during initial med therapy 11. A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempt to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? - Do not administer the lorazepam pts who are in a facility d/t an involuntary admission retain the right to refuse tx. therefore, the nurse should hold the med and document the pts refusal 12. A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? - The client reports command hallucinations the nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a pt who has schizophrenia. command hallucinations can direct the pt to harm themselves or others 13. A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? - Emotional lability it is the rapid transition from one emotion to another an is a primary feature of borderline personality disorder. pts who have BPD react to situations with emotional responses that are out of proportion to the circumstances 14. While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? - The client needs excessive external input to make everyday decisions pts who have dependent personality disorder need excessive input from others to make everyday decisions 15. A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? - Inappropriate dress clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect 16. A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. which of the following strategies should the nurse use when communicating with this client? - Set realistic limits on the clients behavior pts who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. the nurse should establish clear limits on specific aggressive and demanding behaviors 17. A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. which of the following interventions should the nurse take? - Gather supplies for endotracheal intubation the nurse should gather supplies for endotrachial intubation because an expected findings of an unresponsive pt who has alcohol toxicity is resp depression 18. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/ 5 mL. How many mL should the nurse administer? - 14 19. A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? - Encourage frequent rest periods throughout the day a pt who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time w/o sleep. encouraging periods of rest throughout the day can limit the risk of exhaistion 20. A nurse is reviewing routine laboratory values for several clients who re taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? - A client who has a sodium level of 128 mEq/L a sodium level of 128 mEq/L should alert the nurse that the pt is at risk for lithium toxicity bc renal excretion of lithium is decreased in the presence of a low Na level 21. a nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? - Orthostatic hypotension low weight, e imbalances, starvation, and dehydration cause orthostatic hypotension 22. A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? - "If you do my homework for me, I won't bother to for the rest of the day." this is an example of manipulative behavior. it is an ex of this when the family member uses a behavior to get what they desire rather than directly asking for what they want 23. A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? - "In the event a client threatens to harm others, medications can be administered without consent" the charge nurse should inform the participants that their primary commitment is to the pt and their priority is always to advocate for and protect their health and safety. during an emergency situation, if the pt is threatening harm to self or others, meds can be admin w/o pts consent and w/o a court order 24. A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. which of the following actions should the nurse take? - Ask the family member is they have any thoughts or questions about the treatment plan this action involves the family member and allows them a venue to communicate about the pts medication tx plan 25. A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. which of the following is the priority action by the nurse? - Provide frequent high-calorie snacks the priority action the nurse should take when using Maslow's hierarchy of needs is to meet the pts need for adequate nutrition. therefore providing highcalorie snacks is the priority action for the nurse to take 26. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer fist? - Diazepam 5 mg IV bolus the greatest risk to the pt who is experiencing alcohol withdrawal is seizures, an elevated HR, and elevated BP. IV diazepam acts rapidly to prevent seizures, stabilize vital signs and decrease the intensity or withdrawal manifestations 27. A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk or complicated grief? - "I feel so empty without my wife that it's hard to get p every morning." the nurse should identify that when a pt has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief 28. A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. he nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? - Hand tremors