ATI Mental Health 2019 B

1) A nurse is assessing a family’s dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? -An adolescent family member who questions parental authority An adolescent who questions parental authority is demonstrating appropriate behavior for developmental age. -A family with three generations in the same household This scenario occurs in many households, and it is not an indication of a boundary issue. -Older children who are responsible for their younger siblings This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members. -Two adults and their children from prior relationships in the same household This is an example of a blended family, and it is not an indication of a boundary issue. 2) A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse client relationship. Which of the following actions should the nurse take first? -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. -Introduce the client to other clients in the day room. The nurse should introduce the client to other clients in the day room to help the client interact with others during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a different action first. -Assist the client in facilitating behavioral change. The nurse should assist the client with behavioral change during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a different action first. -Determine coping strategies that the client has used in the past. The nurse should determine what coping strategies the client used in the past during the working phase of the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a different action first. 3) A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse’s suspicion of delirium? -Slow onset Delirium has an acute onset. Dementia is a slow, progressive decline. -Aphasia Aphasia is a manifestation of dementia. -Confabulation Confabulation is a manifestation of dementia. -Easily distracted Extreme distractibility is a hallmark manifestation of delirium. 4) A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client’s plan of care? -Offer the client various choices for meal selection. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by limiting the choices the client is asked to make. -Assign different nursing personnel for each shift. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing consistent nursing personnel. -Permit the client to perform daily rituals to decrease anxiety. The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals. -Maintain an environment that has low lighting.