RN VATI Mental Health
1. A nurse is planning care for a client following a suicide attempt. Which ofthe
following interventions should the nurse include in the plan Answer: Provide theclient
with plastic eating utensils.
-The client can use glass dishes and metal silverware to cause self harm, therefore,
the nurse should arrange for the client to have only plastic products on their
mealtray.
2. A nurse is performing an admission assessment for a client who appears
withdrawn and fearful. Which of the following actions should the nurse take first
Answer: Inform the client that this admission is confidential.
-According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse client relationship.This
action establishes trust between the client and the nurse, which in turn decreases the
client's anxiety level.
3. A nurse is caring for an adolescent client who has anorexia nervosa. Theclient
,states,"Have I done any permanent damage to my body?"
,Which of thefollowing responses should the nurse make Answer: You're afraid you
have causedphysical injury to yourself?
-Repeating the main idea of what the client has said, which will allow for
clarificationof any misunderstanding on the part of the client or the nurse.
4. A nurse is caring for a client following a fire that destroyed her home and
killed one of her children. The client is crying and does not make eye contact
with the nurse.Which of the following questions should the nurseask first
Answer: Have you thought of harming yourself?
-The greatest risk to this client is self harm due to the loss of her child and home,
therefore, the first question the nurse should ask a client who is having a
personalcrisis is to determine if the client has suicidal ideation. If so, the nurse should
takeaction to protect the client from self harm.
5. A nurse is checking laboratory values for a hospitalized young adult clientwho
has bipolar disorder and is taking lithium.Which of the following valuesis the
priority for the nurse to report to the provider Answer: Serum creatinine 2.1
mg/dL
-Reference range of 0.5-1.2 mg/dL.
, The greatest risk to this client is decreased kidney function, which can cause
1. A nurse is planning care for a client following a suicide attempt. Which ofthe
following interventions should the nurse include in the plan Answer: Provide theclient
with plastic eating utensils.
-The client can use glass dishes and metal silverware to cause self harm, therefore,
the nurse should arrange for the client to have only plastic products on their
mealtray.
2. A nurse is performing an admission assessment for a client who appears
withdrawn and fearful. Which of the following actions should the nurse take first
Answer: Inform the client that this admission is confidential.
-According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse client relationship.This
action establishes trust between the client and the nurse, which in turn decreases the
client's anxiety level.
3. A nurse is caring for an adolescent client who has anorexia nervosa. Theclient
,states,"Have I done any permanent damage to my body?"
,Which of thefollowing responses should the nurse make Answer: You're afraid you
have causedphysical injury to yourself?
-Repeating the main idea of what the client has said, which will allow for
clarificationof any misunderstanding on the part of the client or the nurse.
4. A nurse is caring for a client following a fire that destroyed her home and
killed one of her children. The client is crying and does not make eye contact
with the nurse.Which of the following questions should the nurseask first
Answer: Have you thought of harming yourself?
-The greatest risk to this client is self harm due to the loss of her child and home,
therefore, the first question the nurse should ask a client who is having a
personalcrisis is to determine if the client has suicidal ideation. If so, the nurse should
takeaction to protect the client from self harm.
5. A nurse is checking laboratory values for a hospitalized young adult clientwho
has bipolar disorder and is taking lithium.Which of the following valuesis the
priority for the nurse to report to the provider Answer: Serum creatinine 2.1
mg/dL
-Reference range of 0.5-1.2 mg/dL.
, The greatest risk to this client is decreased kidney function, which can cause
