RN VATI MENTAL HEALTH 2019 ASSESSMENT
MENTAL HEALTH ASSESSMENT QUESTIONS AND
ANSWERS
A nurse is planning care for a client following a suicide attempt. Which of the
following interventions should the nurse include in the plan?
• Provide the client 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 meal tray.
A nurse is performing an admission assessment for a client who appears
withdrawnand fearful. 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. This action establishes trust between the client and the nurse,
which in turn decreases the client's anxiety level.
A nurse is caring for an adolescent client who has anorexia nervosa. The client
states, "Have I done any permanent damage to my body?" Which of the
following responses should the nurse make?
• You're afraid you have caused physical injury to yourself?
-Repeating the main idea of what the client has said, which will allow for
clarification of any misunderstanding on the part of the client or the nurse.
A nurse is caring for a client following a fire that destroyed her home and killed
oneof her children. The client is crying and does not make eye contact with the
nurse.
,Which of the following questions should the nurse ask first?
• 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 personal crisis is to determine if the client has suicidal ideation. If so, the
nurse should take action to protect the client from self harm.
A nurse is checking laboratory values for a hospitalized young adult client who
has bipolar disorder and is taking lithium. Which of the following values is the
priorityfor the nurse to report to the provider?
• 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 an
increase in the client's lithium level; therefore, this value is the priority for the
nurse to report to the provider. The clients lithium dosage might need to be
modified based on this lab value. The cause of increased serum creatinine
include dehydration as well as renal disorders. Lithium is contraindicated for
clients who have severe renal disease, cardiac disease, or severe dehydration.
A nurse is providing information to a client who is seeking voluntary admission
to a mental health facility. Which of the following information should the nurse
include?
• You will still need to give informed consent for treatment after admission.
-A client who seeks voluntary admission to a mental health facility has the same
rights as clients receiving any other kind of health care. The client will still need
to give informed consent for treatment and therapies, such as electroconvulsive
therapy.
A nurse is developing a plan of care for an adolescent client who has conduct
disorder. Which of the following interventions should the nurse include in the
plan?
, • Initiate a behavioral contract with the client.
-A client who has conduct disorder can demonstrate patterns of behavior that are
aggressive, disrespectful of others rights, and can lead to injury of others. A
behavioral contract helps to develop trust between the client and the nurse and
emphasizes the client's responsibility to commit to work on changes in behavior.
A hospice nurse is talking with the family of a client who recently died from
cancer following a series of chemotherapy treatment. One of the adult children is
angry withthe provider and blames the provider for their father's death. Which of
the following defense mechanisms is the family member using?
• Displacement
-When this family member uses displacement, they are transferring their
feelings of anger to the provider so they do not have to cope with their own
feelings of sadness and loss.
A nurse in an acute care facility is providing teaching for the adult child of an
olderadult client who is admitted with a urinary tract infection and delirium. The
client has been living independently at home. Which of the following statements
by the adult child demonstrates the teaching has been effective?
• I expect that my father will no longer be confused when he is discharged.
A nurse is caring for a client who is experiencing a manic episode. Which
of thefollowing actions should the nurse take first?
• Encourage the client to rest each hour.
-The greatest risk to this client is injury from exhaustion due to the manic phase,
therefore, the priority action the nurse should take is to encourage the client to
rest for 3-5mins every hour.
A nurse is leading a medication education group for several clients. A client who
is sometimes violent becomes angry and begins yelling at others in the group.
Which ofthe following actions should the nurse take?
MENTAL HEALTH ASSESSMENT QUESTIONS AND
ANSWERS
A nurse is planning care for a client following a suicide attempt. Which of the
following interventions should the nurse include in the plan?
• Provide the client 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 meal tray.
A nurse is performing an admission assessment for a client who appears
withdrawnand fearful. 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. This action establishes trust between the client and the nurse,
which in turn decreases the client's anxiety level.
A nurse is caring for an adolescent client who has anorexia nervosa. The client
states, "Have I done any permanent damage to my body?" Which of the
following responses should the nurse make?
• You're afraid you have caused physical injury to yourself?
-Repeating the main idea of what the client has said, which will allow for
clarification of any misunderstanding on the part of the client or the nurse.
A nurse is caring for a client following a fire that destroyed her home and killed
oneof her children. The client is crying and does not make eye contact with the
nurse.
,Which of the following questions should the nurse ask first?
• 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 personal crisis is to determine if the client has suicidal ideation. If so, the
nurse should take action to protect the client from self harm.
A nurse is checking laboratory values for a hospitalized young adult client who
has bipolar disorder and is taking lithium. Which of the following values is the
priorityfor the nurse to report to the provider?
• 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 an
increase in the client's lithium level; therefore, this value is the priority for the
nurse to report to the provider. The clients lithium dosage might need to be
modified based on this lab value. The cause of increased serum creatinine
include dehydration as well as renal disorders. Lithium is contraindicated for
clients who have severe renal disease, cardiac disease, or severe dehydration.
A nurse is providing information to a client who is seeking voluntary admission
to a mental health facility. Which of the following information should the nurse
include?
• You will still need to give informed consent for treatment after admission.
-A client who seeks voluntary admission to a mental health facility has the same
rights as clients receiving any other kind of health care. The client will still need
to give informed consent for treatment and therapies, such as electroconvulsive
therapy.
A nurse is developing a plan of care for an adolescent client who has conduct
disorder. Which of the following interventions should the nurse include in the
plan?
, • Initiate a behavioral contract with the client.
-A client who has conduct disorder can demonstrate patterns of behavior that are
aggressive, disrespectful of others rights, and can lead to injury of others. A
behavioral contract helps to develop trust between the client and the nurse and
emphasizes the client's responsibility to commit to work on changes in behavior.
A hospice nurse is talking with the family of a client who recently died from
cancer following a series of chemotherapy treatment. One of the adult children is
angry withthe provider and blames the provider for their father's death. Which of
the following defense mechanisms is the family member using?
• Displacement
-When this family member uses displacement, they are transferring their
feelings of anger to the provider so they do not have to cope with their own
feelings of sadness and loss.
A nurse in an acute care facility is providing teaching for the adult child of an
olderadult client who is admitted with a urinary tract infection and delirium. The
client has been living independently at home. Which of the following statements
by the adult child demonstrates the teaching has been effective?
• I expect that my father will no longer be confused when he is discharged.
A nurse is caring for a client who is experiencing a manic episode. Which
of thefollowing actions should the nurse take first?
• Encourage the client to rest each hour.
-The greatest risk to this client is injury from exhaustion due to the manic phase,
therefore, the priority action the nurse should take is to encourage the client to
rest for 3-5mins every hour.
A nurse is leading a medication education group for several clients. A client who
is sometimes violent becomes angry and begins yelling at others in the group.
Which ofthe following actions should the nurse take?
