ATI Mental Health Exam 3

ATI Mental Health Exam 3 • Question 1 1 out of 1 points The nurse is assessing a patient who has been diagnosed with hypochondriasis. Which clinical manifestation would the nurse most likely assess in this patient? Selected Answer: Misinterpretation of physical sensations as evidence of serious illness Answers: Loss of interest in formerly pleasurable activities Repetitive, time-consuming rituals Deliberate fabrication of symptoms for an obvious benefit Misinterpretation of physical sensations as evidence of serious illness Response Feedback: People with hypochondriasis experience severe distress, and their ability to function in personal, social, and occupational roles often is impaired. Most patients with hypochondriasis present with somatic symptoms as well as total preoccupation with the belief of having a devastating sickness or disease. These individuals are thought to have prominent health anxiety (hypochondriasis), another form of hypochondriasis. They have minimal or no somatic symptoms but reveal a disproportionate or excessive preoccupation with having a serious illness. • Question 2 1 out of 1 points What is the priority nursing diagnosis for a patient who is experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? Selected Answer: Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait Answers: Bathing/hygiene self-care deficit related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations Fear related to sensory perceptual alterations, as evidenced by hiding from Response Feedback: hallucinated dog and asking nurse to remove hallucinated bugs from legs The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient’s sensorium is clouded. The other diagnoses are concerns, but are lower priorities. • Question 3 1 out of 1 points What is a nurse’s legal responsibility if child abuse or neglect is suspected? Selected Answer: Report the suspected abuse or neglect according to state regulations Answers: Discuss the findings with the child’s teacher, principal, and school psychologist Report the suspected abuse or neglect according to state regulations Document the observations and speculations in the medical record Continue the assessment. Response Feedback: Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be absolutely sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. • Question 4 1 out of 1 points A patient sat in silence for 20 minutes after a therapy appointment. The patient appeared tense and vigilant. The patient abruptly stood up and paced back and forth across the day room, clenching and unclenching his fists. Next, he stopped and stared intently into the face of a psychiatric technician. Which of the following best explains the nurse’s observations of this patient? Selected Answer: The patient is exhibiting clues to potential aggression. Answers: The patient is demonstrating withdrawal The patient is working off angry feelings. The patient is using relaxation strategies effectively. The patient is exhibiting clues to potential aggression. Response Feedback: The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing. • Question 5 1 out of 1 points A patient being assessed for somatoform pain disorder says, “My pain is from an undiagnosed injury. I can’t perform my own activities of daily living or walk 20 minutes. I have to take pain medicine six or seven times a day. I feel like a baby because my family has to provide so much care for me.” Which of the following does the nurse understand is most important to include as part of this assessment? Selected Answer: secondary gain. Answers: mood. cognitive style. secondary gain. identity and memory Response Feedback: Secondary gain should be assessed. The patient’s dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient’s diagnosis has been established. • Question 6 1 out of 1 points A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food, but doesn’t pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try first? Selected Answer: Hand the fork to the client and say, “Use this fork to eat your meat loaf.” Answers: Send the food back to the kitchen and try something else