ATI Capstone: Mental Health EXAM

A nurse in an acute care facility is assisting with the admission of an older adult client who has late stage Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his partner. Which of the following actions should the nurse take first? - answerAsk the partner to talk about his difficulties in caring for the client. The first action the nurse should take, using the nursing process priority framework, is to collect data regarding the partner's ability to take care of the client. A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates the medications is effective? - answerDecrease in urge to smoke Bupropion is an antidepressant that is also used for smoking cessation. A nurse is evaluating the outcome for a client who has depression following the death of his wife 3 months ago. Which of the following client statements indicates a need for further intervention? - answer"I just don't feel like eating because I never like to eat alone." At risk for malnutrition and injury. A nurse in a long-term care setting is caring for a client who has Alzheimer's disease. The client states, "I just came back from a hard day's work in my office." The nurse should identify this statement is an example of which of the following coping mechanisms? - answerConfabulation Confabulation is the creation of information which is untrue to fill in gaps in memory and to protect self-esteem in clients who have dementia. A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse- client relationship? - answerUse active listening when with the client. The nurse should use active listening to establish presence with the client. presence involves eye contact, body language, voice tone, listening, and reflection to convay openness and understanding. A nurse is assessing a client in the emergency department who drank alcohol while taking disulfiram. The client states, "The nurse told me not to drink when taking the medication. I am just a social drinker. I didn't realize that having just one drink with my friends would cause such a problem." Which of the following defense mechanisms is the client demonstrating? - answerRationalization The client is demonstrating rationalization when he creates reasonable and acceptable explanations for unacceptable behavior. The client is using rationalization asa defense mechanisms to justify why he had just one drink. Even though the nurse told him not to drink alcohol. A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium? - answerA client asks when family members will be arriving after visiting 1 hr earlier. Delirium is characterized by a change in cognition that occurs over a short period of time. It always results from secondary physiological condition, ( infection, surgery, prolonged hospitalization, hypoxia, fever, medication) and is a transient disorder. Although delirium can occur at any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome" A nurse is collecting data from a client newly admitted for anorexia nervousa. Which of the following findings should the nurse expect? - answerAmenorrhea The nurse should expect the client to report amenorrhea due to low body weight. A nurse is collecting data from a client who has bipolar disorder with main. Which of the following findings is the nurse's priority? - answerThe client paces in the hallway during the day and most of the night. When using Maslow's hierarchy of needs, the nurse determines that the priority findings is the client's physiological need for rest and food. Nonstop activity is an emergency situation for a client who has mania, since the client might go for long periods without eating or sleep. A nurse is preparing to assist with the care of a client of a client who is undergo electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? SATA - answer- Electroencephalogram (EEG) monitor. The provider will monitor the client's brainwave patterns during the procedure. - Oxygen saturation monitor The client requires continuous oxygen saturation monitoring because she will receive a short-acting barbiturate to induce sleep and a muscle-paralyzing agent to prevent muscle distress and injury. -Electrocardiogram (ECG) monitor. The provider will monitor the client's cardiac response during the procedure. A nurse is assisting with a family therapy session for parents and 2 school-age children. Which of the following statements should the nurse recognize as an example of effective communication among family members? - answer"Can you tell me the reason you get upset each time I go to the mall?" This is an expel of effective and healthy communication. Healthy communication expresses clear, understandable messages between family members. Each family member is encourage to express his or her feelings and thoughts. A n urse is reinforcing teaching with a client who is 2 days postpartum and has a history of postpartum depression. Which of the following instructions should the nurse include? - answerSleep as much as possible. The nurse should encourage the client to sleep as much as she can during the next few weeks. Sleep deprivation can increase the risk for postpartum depression. A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the following statements by the client indicates an understanding of the teaching? - answer"I will contact my provider if I have difficulty urinating" Chlorpromazine is a first-generation, or typical, antipsychotic medication prescribed for schizophrenia. The client should monitor for anticholinergic adverse effects, such as dry mouth and urinary retention. Difficulty urinating could be a sign of urinary retention and should be reported to the provider for further evaluation. A nurse is collecting data from a client following a recent suicide attempt. Which of the following findings in the client's history places him at the greatest risk for another suicide attempt? - answerImpulsivity A client who has impulsivity is at risk for suicide because he is more likely to take an action quickly without thinking about the consequences. A nurse is caring for client who escapes anxiety - causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms? - answerUndoing The nurse correctly identifies this as an example of denial which is escaping unpleasant or anxiety - causing thoughts or feelings by ignoring their existence. A nurse is caring for an older adult client who is scheduled for surgery. The client becomes upset when the nurse asks her to remove her dentures prior to the surgery. Which of the following is a therapeutic response by the nurse? - answer" You seem worried. Are you concerned someone may see you without your teeth?" The nurse uses two therapeutic communication tools in this response. One is empathy, which is shown by focusing on the client's feelings. The other is validation/clarification, in which the nurse seeks to validate the reason for the client's feelings. A nurse is talking with a client who has schizophrenia. Suddenly the client states, "Im tightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate ? - answer"What are the voices telling you to do?" This statement recognizes the risk involved with a command hallucination an asks there client directly about the hallucination. This is a therapeutic approach to communicating with a client who is experiencing a hallucination. A nurse is collecting data from a client who has a major depressive disorder (MDD). Which of the following findings should the nurse expect? - answerSignificant change in weight A signifi