PN VATI MENTAL HEALTH QUESTIONS AND
ANSWERS 2023-2024 A+ GUIDE
A nurse is assisting with the care of a client immediately following electroconvulsive
therapy (ECT). Which of the following findings should the nurse document as an
unexpected response to the procedure? - Correct Answer- Irregular heart rhythm
An irregular heart rhythm is an unexpected response to ECT. During the procedure,
the client's heart can be stressed, which can cause cardiac abnormalities. especially
if the client already has impaired cardiac function. The nurse should document this
finding and notify the charge nurse or the client's provider.
A nurse is caring for a client who is admitted for alcohol use disorder. The client
states, "I have not had anything to drink for 24 hours." Which the following is the
priority nursing intervention? - Correct Answer- Check the client's vital signs.
Clients who have alcohol use disorder are at risk for the development of abstinence
syndrome. Manifestations of abstinence syndrome occur 12 to 72 hr after the client
has last consumed alcohol and can include tachycardia, hypertension, and an
elevated temperature. Therefore, the first action the nurse should take when using
the airway, breathing, circulation (ABC) approach to client care is to check the
client's vital signs to monitor for signs of abstinence syndrome.
A nurse is reinforcing teaching with the adult child of a client who is scheduled to
have electroconvulsive therapy (ECT). Which of the following statements should the
nurse make? - Correct Answer- "Your father might experience short-term memory
loss after the procedure."
The nurse should reinforce to the client's child that short-term memory loss is a
common adverse effect of ECT.
A nurse is assisting with planning care for a client who is in the manic phase of
bipolar disorder. Which of the following actions is the priority for the nurse to include
in the plan? - Correct Answer- Offer frequent high-calorie fluids throughout the day.
The priority action the nurse should take when using Maslow's hierarchy of needs is
to meet the client's physiological need for food and fluids. The priority nursing action
is to frequently.offer the client high-calorie fluids to prevent dehydration and ensure
the client's caloric is adequate to meet intake physical needs.
A nurse is reinforcing teaching with a client who has bipolar disorder and a new
prescription for valproic acid. Which of the following manifestations should the nurse
instruct the client to report to the provider as an adverse effect of this medication? -
Correct Answer- Abdominal pain
, The nurse should instruct the client that abdominal pain can indicate hepatoxicity or
pancreatitis, both adverse effects of valproic acid; therefore, the client should report
this to the provider.
A nurse is establishing a therapeutic relationship with a client who has generalized
anxiety disorder. Which of the following actions should the nurse take first? - Correct
Answer- Explain confidentiality guidelines to the client.
Evidence-based practice indicates that the nurse should first begin a therapeutic
relationship with the orientation phase. During this phase, the nurse should explain
the guidelines for confidentiality. This initial step in developing a therapeutic
relationship builds trust between the client and the nurse.
A nurse is interviewing an adolescent client who reports that they were sexually
assaulted. Which of the following actions should the nurse take? - Correct Answer-
Move the client to a private examination room to perform the interview.
The nurse should interview the client in a private room without others present.
Providing privacy in a safe environment will foster trust and promote open
communication between the client and the nurse.
A nurse is caring for a client who is experiencing a severe panic attack. Which of the
following actions should the nurse take during the panic attack? (Select all that
apply.) - Correct Answer- Stay with the client is correct. The nurse should stay with
the client during the panic attack to ensure that the client remains safe and reduce
feelings of abandonment.
Instruct the client to take slow, deep breaths is correct. The nurse should instruct the
client to breathe slowly and deeply to distract from the distressing manifestations of
the attack and reduce the risk for hyperventilation.
Set physical limits is correct. The nurse should set physical limits to maintain the
safety of the client and others because the client might have difficulty controlling their
actions during the attack.
A nurse is collecting data from a 5-year-old child who is brought to the emergency
department by a parent who states that the child fell out of a tree. The child is
guarding their right arm. For which of the following findings should the nurse suspect
physical maltreatment? - Correct Answer- An x-ray of the right arm indicates a spiral
fracture.
The nurse should identify that an x-ray indicating a fracture can be an expected
finding for a child who fell out of a tree. However, a spiral fracture is caused by
twisting of the extremity and can be an indication of physical maltreatment. The
nurse should report the findings to the registered nurse.
ANSWERS 2023-2024 A+ GUIDE
A nurse is assisting with the care of a client immediately following electroconvulsive
therapy (ECT). Which of the following findings should the nurse document as an
unexpected response to the procedure? - Correct Answer- Irregular heart rhythm
An irregular heart rhythm is an unexpected response to ECT. During the procedure,
the client's heart can be stressed, which can cause cardiac abnormalities. especially
if the client already has impaired cardiac function. The nurse should document this
finding and notify the charge nurse or the client's provider.
A nurse is caring for a client who is admitted for alcohol use disorder. The client
states, "I have not had anything to drink for 24 hours." Which the following is the
priority nursing intervention? - Correct Answer- Check the client's vital signs.
Clients who have alcohol use disorder are at risk for the development of abstinence
syndrome. Manifestations of abstinence syndrome occur 12 to 72 hr after the client
has last consumed alcohol and can include tachycardia, hypertension, and an
elevated temperature. Therefore, the first action the nurse should take when using
the airway, breathing, circulation (ABC) approach to client care is to check the
client's vital signs to monitor for signs of abstinence syndrome.
A nurse is reinforcing teaching with the adult child of a client who is scheduled to
have electroconvulsive therapy (ECT). Which of the following statements should the
nurse make? - Correct Answer- "Your father might experience short-term memory
loss after the procedure."
The nurse should reinforce to the client's child that short-term memory loss is a
common adverse effect of ECT.
A nurse is assisting with planning care for a client who is in the manic phase of
bipolar disorder. Which of the following actions is the priority for the nurse to include
in the plan? - Correct Answer- Offer frequent high-calorie fluids throughout the day.
The priority action the nurse should take when using Maslow's hierarchy of needs is
to meet the client's physiological need for food and fluids. The priority nursing action
is to frequently.offer the client high-calorie fluids to prevent dehydration and ensure
the client's caloric is adequate to meet intake physical needs.
A nurse is reinforcing teaching with a client who has bipolar disorder and a new
prescription for valproic acid. Which of the following manifestations should the nurse
instruct the client to report to the provider as an adverse effect of this medication? -
Correct Answer- Abdominal pain
, The nurse should instruct the client that abdominal pain can indicate hepatoxicity or
pancreatitis, both adverse effects of valproic acid; therefore, the client should report
this to the provider.
A nurse is establishing a therapeutic relationship with a client who has generalized
anxiety disorder. Which of the following actions should the nurse take first? - Correct
Answer- Explain confidentiality guidelines to the client.
Evidence-based practice indicates that the nurse should first begin a therapeutic
relationship with the orientation phase. During this phase, the nurse should explain
the guidelines for confidentiality. This initial step in developing a therapeutic
relationship builds trust between the client and the nurse.
A nurse is interviewing an adolescent client who reports that they were sexually
assaulted. Which of the following actions should the nurse take? - Correct Answer-
Move the client to a private examination room to perform the interview.
The nurse should interview the client in a private room without others present.
Providing privacy in a safe environment will foster trust and promote open
communication between the client and the nurse.
A nurse is caring for a client who is experiencing a severe panic attack. Which of the
following actions should the nurse take during the panic attack? (Select all that
apply.) - Correct Answer- Stay with the client is correct. The nurse should stay with
the client during the panic attack to ensure that the client remains safe and reduce
feelings of abandonment.
Instruct the client to take slow, deep breaths is correct. The nurse should instruct the
client to breathe slowly and deeply to distract from the distressing manifestations of
the attack and reduce the risk for hyperventilation.
Set physical limits is correct. The nurse should set physical limits to maintain the
safety of the client and others because the client might have difficulty controlling their
actions during the attack.
A nurse is collecting data from a 5-year-old child who is brought to the emergency
department by a parent who states that the child fell out of a tree. The child is
guarding their right arm. For which of the following findings should the nurse suspect
physical maltreatment? - Correct Answer- An x-ray of the right arm indicates a spiral
fracture.
The nurse should identify that an x-ray indicating a fracture can be an expected
finding for a child who fell out of a tree. However, a spiral fracture is caused by
twisting of the extremity and can be an indication of physical maltreatment. The
nurse should report the findings to the registered nurse.
