ATI RN Mental Health Online Practice 2024 A

A school nurse is assessing a school aged child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD) 1. Clinging behaviors directed toward a teacher 2. Increased time spent sleeping 3. Intense focus on school work 4. Lack of interest in an upcoming holiday - answersCorrect = 4. Lack of interest in an upcoming holiday The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events (e.g., Holidays) *PTSD manifestations seen in children include detachment or estrangement from others, difficulty sleeping/distressing dreams, difficulty concentrating on tasks A nurse is caring for a group of clients. Which of the following finding should the nurse report? 1. A client who is taking clozapine and has a WBC count of 7,500 2. A client who is taking lamotrigine and has developed a rash 3. A client who is taking valproate and has a platelet count of 150,000 4. A client who is taking lithium and has a lithium level of 1.2 - answersCorrect = 2. A client who is taking lamotrigine and has developed a rash Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life threatening adverse effect of the medication and report the finding immediately A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as contraindication for receiving clozapine? 1. WBC count 2,500 2. Hgb 11.5 3. Platelets 150,000 4. RBC count 3.5 - answersCorrect - 1. WBC count 2,500 Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? 1. "I'm relieved now that my financial affairs are in order." 2. "It is easier to talk about my feelings now." 3. "Suddenly I have enough energy to do anything I want." 4. "Thank you for always taking such good care of me." - answersCorrect - 2. "It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome *When clients who have depression verbalize getting their affairs in order, or suddenly have more energy are at an increased risk of suicide. Clients who have depression often show an appreciation for loved ones when they are contemplating suicide During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? 1. The client is interested in what the nurse is saying 2. The client is attempting to manipulate the nurse 3. The client is physically attracted to the nurse 4. The client is seeking acceptance by the nurse - answersCorrect - 1. The client is interested in what the nurse is saying The client's posture and eye contact demonstrate an interest in the interview and what the nurse is saying A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? 1. Promote use of music to compete with the client's auditory hallucination 2. Inform the client that the auditory hallucinations are not real 3. Avoid asking the client if they are experiencing auditory hallucinations 4. Instruct the client on the use of voice recognition regarding the auditory hallucinations - answersCorrect = 1. Promote the use of music to compete with the client's auditory hallucinations Competing reality based stimulating such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level *The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that others cannot hear anything to reinforce reality. The nurse should ask the client if they are hearing voices to evaluate whether these are command hallucinations, which can place the client or others at risk for harm. The nurse should assist the client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to stop, which gives the client a sense of control A nurse is caring for a client who has impaired cognition A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client