Mental Health ATI - Assessment A
A customer is experiencing a situational crisis. Which of the following findings have to the nurse
assume? - ANS-Client lately lost a grandparent in a motor car crash. (Client stories a situational
disaster when an sudden occasion takes place.)
A patron who has paranoid schizophrenia is attending a remedy making plans conference with a
family member. During the discussion of medication adherence portion of the plan, the nurse
notices that the member of the family appears distracted. Which of the following is the ideal
motion by means of the nurse? - ANS-Ask the family member if she has any mind or questions
about this portion of the remedy plan. (Nurse's motion entails the member of the family and
allows her a venue to speak approximately the consumer's medicine treatment plan.)
A domestic fitness nurse is assessing an older person consumer who lives alone. Which of the
subsequent findings must illustrate to the nurse that the client is experiencing delirium? -
ANS-Sudden onset. (Clients usually expand delirium all of sudden over hours to days.)
A nurse in intellectual health facility observes a consumer who's experiencing panic degree of
anxiety. Which of the subsequent movements must the nurse take first? - ANS-Accompany the
client to a quiet room. (Greatest risk for this patron is harm due to excessive tension. Therefore,
first movement nurse ought to take is to live with purchaser and bring him to a room with
minimal stimuli.)
A nurse is assessing a customer inside the ED who is added in through a caregiver. The
caregiver states the customer fell recently. The nurse observes bruises at the client's abdomen,
lower back, and legs suspects abuse. Which of the subsequent moves must the nurse take
first? - ANS-Check the customer for different s/s of abuse. (First action the nurse have to take
the use of nursing manner is to evaluate consumer. Therefore, first motion the nurse must take
is to check patron for in addition s/s of abuse.)
A nurse is assessing a patron inside the ED. Client seems agitated, his blood strain is
152/ninety four mm Hg, his HR is 104/min, and his pupils are dilated. The nurse ought to
suspect intoxication with which of the following substances? - ANS-Cocane (cocaine intoxication
reasons tachycardia, increased BP, dilated pupils, and agitation. These physiological findings
advise cocaine intoxication).
A nurse is worrying for a child who has behavior disorder and is behaving in a destructive way,
throwing gadgets, and kicking others. Which of the subsequent healing nursing interventions in
the maximum precedence? - ANS-Use a healing maintaining technique. (Greatest hazard to this
toddler and others is damage; consequently, nurse's precedence intervention is to apply a
healing retaining technique to deescalate the behavior and prevent damage)
, A nurse is worrying for a purchaser for a consumer who has alcoholic cardiomyopathy. Which of
the subsequent laboratory values ought to the nurse assume? - ANS-Increased creatinine
phosphokinase (CPK) [increase in CPK, a muscle enzyme released when muscle tissue is
damaged, occurs with cardiomyopathy]
A nurse is worrying for a patron receiving imipramine for depression. For which of the following
damaging consequences must the nurse screen? - ANS-Urinary retention.
A nurse is being concerned for a consumer who has a history of substance use and turned into
involuntarily admitted to a intellectual sanatorium. When the nurse tries to administer oral
lorazepam, the patron refuses to take the medicine and will become physically competitive.
Which of the following actions have to the nurse take? - ANS-Do now not administer the
lorazepam. (Clients who are involuntarily admitted preserve the proper to refuse treatment.)
A nurse is being concerned for a patron who has schizophrenia and is prescribed risperidone.
Which of the subsequent laboratory tests should the nurse display? - ANS-Blood glucose
(risperidone can motive diabetes mellitus to broaden; therefore, nurse ought to plan to monitor
client's blood glucose degree while taking this medicine)
A nurse is being concerned for a patron who has schizophrenia in a mental clinic. Which of the
following locations the client at finest threat for self-directed injury or injuring others? -
ANS-Command hallucinations (a client who has schizophrenia and is experiencing command
hallucinations can be instructed to hurt himself or others. Therefore, a client who is experiencing
command hallucinations is at best chance for self-directed damage or injuring others).
A nurse is being concerned for a patron who is deaf and is scheduled to have electroconvulsive
therapy (ECT). Provider needs to give an explanation for system to client with a purpose to gain
informed consent. Which of the subsequent movements must the nurse take? - ANS-Request a
expert interpreter to translate.
A nurse is caring for a customer who's experiencing acute alcohol withdrawal. Which medicinal
drugs have to the nurse administer? - ANS-Chlordiazepoxide (prevents withdrawal signs and
symptoms)
A nurse is caring for a client with dementia. Which of the following interventions is beneficial for
orienting a consumer to reality? - ANS-Place a huge wall calendar inside the customer's room.
(orient to reality of day, month, and yr)
A nurse is being concerned for customer whose toddler currently died in a motor car crash and
states, "I just need to join him." Which of the following is the nurse's precedence reaction? -
ANS-"Are you considering harming yourself?" (Greatest chance is self-harm; precedence is
therefore to invite patron if she has plans for self-damage)
A customer is experiencing a situational crisis. Which of the following findings have to the nurse
assume? - ANS-Client lately lost a grandparent in a motor car crash. (Client stories a situational
disaster when an sudden occasion takes place.)
A patron who has paranoid schizophrenia is attending a remedy making plans conference with a
family member. During the discussion of medication adherence portion of the plan, the nurse
notices that the member of the family appears distracted. Which of the following is the ideal
motion by means of the nurse? - ANS-Ask the family member if she has any mind or questions
about this portion of the remedy plan. (Nurse's motion entails the member of the family and
allows her a venue to speak approximately the consumer's medicine treatment plan.)
A domestic fitness nurse is assessing an older person consumer who lives alone. Which of the
subsequent findings must illustrate to the nurse that the client is experiencing delirium? -
ANS-Sudden onset. (Clients usually expand delirium all of sudden over hours to days.)
A nurse in intellectual health facility observes a consumer who's experiencing panic degree of
anxiety. Which of the subsequent movements must the nurse take first? - ANS-Accompany the
client to a quiet room. (Greatest risk for this patron is harm due to excessive tension. Therefore,
first movement nurse ought to take is to live with purchaser and bring him to a room with
minimal stimuli.)
A nurse is assessing a customer inside the ED who is added in through a caregiver. The
caregiver states the customer fell recently. The nurse observes bruises at the client's abdomen,
lower back, and legs suspects abuse. Which of the subsequent moves must the nurse take
first? - ANS-Check the customer for different s/s of abuse. (First action the nurse have to take
the use of nursing manner is to evaluate consumer. Therefore, first motion the nurse must take
is to check patron for in addition s/s of abuse.)
A nurse is assessing a patron inside the ED. Client seems agitated, his blood strain is
152/ninety four mm Hg, his HR is 104/min, and his pupils are dilated. The nurse ought to
suspect intoxication with which of the following substances? - ANS-Cocane (cocaine intoxication
reasons tachycardia, increased BP, dilated pupils, and agitation. These physiological findings
advise cocaine intoxication).
A nurse is worrying for a child who has behavior disorder and is behaving in a destructive way,
throwing gadgets, and kicking others. Which of the subsequent healing nursing interventions in
the maximum precedence? - ANS-Use a healing maintaining technique. (Greatest hazard to this
toddler and others is damage; consequently, nurse's precedence intervention is to apply a
healing retaining technique to deescalate the behavior and prevent damage)
, A nurse is worrying for a purchaser for a consumer who has alcoholic cardiomyopathy. Which of
the subsequent laboratory values ought to the nurse assume? - ANS-Increased creatinine
phosphokinase (CPK) [increase in CPK, a muscle enzyme released when muscle tissue is
damaged, occurs with cardiomyopathy]
A nurse is worrying for a patron receiving imipramine for depression. For which of the following
damaging consequences must the nurse screen? - ANS-Urinary retention.
A nurse is being concerned for a consumer who has a history of substance use and turned into
involuntarily admitted to a intellectual sanatorium. When the nurse tries to administer oral
lorazepam, the patron refuses to take the medicine and will become physically competitive.
Which of the following actions have to the nurse take? - ANS-Do now not administer the
lorazepam. (Clients who are involuntarily admitted preserve the proper to refuse treatment.)
A nurse is being concerned for a patron who has schizophrenia and is prescribed risperidone.
Which of the subsequent laboratory tests should the nurse display? - ANS-Blood glucose
(risperidone can motive diabetes mellitus to broaden; therefore, nurse ought to plan to monitor
client's blood glucose degree while taking this medicine)
A nurse is being concerned for a patron who has schizophrenia in a mental clinic. Which of the
following locations the client at finest threat for self-directed injury or injuring others? -
ANS-Command hallucinations (a client who has schizophrenia and is experiencing command
hallucinations can be instructed to hurt himself or others. Therefore, a client who is experiencing
command hallucinations is at best chance for self-directed damage or injuring others).
A nurse is being concerned for a patron who is deaf and is scheduled to have electroconvulsive
therapy (ECT). Provider needs to give an explanation for system to client with a purpose to gain
informed consent. Which of the subsequent movements must the nurse take? - ANS-Request a
expert interpreter to translate.
A nurse is caring for a customer who's experiencing acute alcohol withdrawal. Which medicinal
drugs have to the nurse administer? - ANS-Chlordiazepoxide (prevents withdrawal signs and
symptoms)
A nurse is caring for a client with dementia. Which of the following interventions is beneficial for
orienting a consumer to reality? - ANS-Place a huge wall calendar inside the customer's room.
(orient to reality of day, month, and yr)
A nurse is being concerned for customer whose toddler currently died in a motor car crash and
states, "I just need to join him." Which of the following is the nurse's precedence reaction? -
ANS-"Are you considering harming yourself?" (Greatest chance is self-harm; precedence is
therefore to invite patron if she has plans for self-damage)
