ATI PN Mental Health Proctored Exam A

ATI PN Mental Health Proctored Exam A A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the patient’s ability to cope with this situation? - "To whom do you talk when you feel overwhelmed?" - By asking this question, the nurse is assessing the client’s support system, which is an important factor in the client’s ability to cope with the situation. A nurse is caring for a patient who gave birth to a stillborn baby. Which of the following statements should the nurse make? - "I'll stay with you just in case you want to talk." - This response indicates the nurse’s interest in the client and a desire to understand the client’s feelings. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hours ago following a motor-vehicle crash. The client’s admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? - BP 154/96 mm Hg - Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3°C (101°F). It will be important for the nurse to rule out infection in the client who has fever. A nurse is teaching a family member and a client who has a sew diagnosis of Alzheimer’s disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? - "Take this medication in the evening at bedtime." - The client should take this medication in the evening for optimal effectiveness. - A client should never double the dose after a missed dose due to adverse effects of the medication but should notify the provider. Chewing, crushing, or splitting the medication can affect the absorption of the medication. If the client has difficulty swallowing, the provider can prescribe orally disintegrating tablets. A nurse is discussing a 12-step program with a patient who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? - The client should obtain a sponsor before discharge for an increased chance of recovery. - This is because the client-sponsor relationship has been shown to increase program attendance and the chances of recovery. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? - Assess the client for evidence of a perceptual disturbance. - The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions). A nurse is admitting a patient with major depression disorder and a new prescription for tranylcypromine. Which of the following OTC medications that the patient reports taking should alert the nurse to a potential adverse reaction? - Phenylephrine - Tranylcypromine is an MAOI antidepressant, which should not be taken with phenylephrine and other OTC medications for sinus congestions, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension. A nurse is assessing a patient with schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? - Anhedonia - Negative symptoms of schizophrenia affect a person’s ability to interact with others and are less dominant than the positive symptoms. These symptoms develop over time. Examples are flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking. A nurse emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? - "She won't let me take the trash from her room. I'm concerned about what she has in there." - The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother’s statement indicates awareness of her daughter’s behavior. A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? - Greater risk of attempting suicide as affect and energy improve. - An initial response to amitriptyline can develop in 1 week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is more possible after 1 week or treatment. A nurse in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include? - Experiences feelings of isolation - Clients who have PTSD often feel estranged and detached from others. A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization? - Temperature 35.6°C (96.1°F) - Severe hypothermia, a temperature lower than 36°C (96.8°F) due to loss of subcutaneous tissue or dehydration requires hospitalization. A nurse is caring for a client who is experiencing alcohol withdrawals. Which of the following medications should the nurse administer first? - Diazepam 5 mg IV bolus - The greatest risk to the client experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations. A patient with a diagnosis of depression is attending a group therapy. During the meeting, the nurse asks each member to identify one goal for the day. When it is the client’s turn, she does not respond. Which of the following actions should the nurse take before repeating the request to the patient? - Allow the client time to collect her thoughts. - Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question. A nurse observes a patient who has acute mania hit another patient first action to take? - Call for a team of staff members to help with the situation. - The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others. A nurse is providing teaching to a patient who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? - Wear sunglasses when outdoors. - Light therapy, or phototherapy, can cause eye strain and sensitivity to light. A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the following statements indicates that the client teaching regarding the medication has been effective? - "I should eat a regular diet with normal amounts of salt and fluids." - This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? - Spending adequate time with a client who is verbally abusive. - By spending time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care. A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take? - Suggest forming a weekly support group for parents who have experienced the loss of a child. - Support groups are q positive resource in the process of recovery for parents who have lost a child. A nurse in a mental health clinic is planning care 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 client is injury resulting from drowsiness or dizziness. Therefore, the nurse’s priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy. A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (select all) - Occupational therapy - Meal delivery services - Physical therapy - Home health services. - An occupational therapist can assist the client to perform ADL’s. Meal delivery services are necessary due to the client’s difficulty performing ADL’s. A physical therapist can assess the client’s mobility needs and assist with ADL’s. Home health services provide a nursing assessment of the client’s physical and mental status, as well as assistance with ADL’s. A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following valu