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ATI RN MENTAL HEALTH ONLINE PRACTICE 2019 B EXAM WITH RATIONALE • A nurse is caring for an older adult client who begins to cry and states, " I knew God would punish me and I deserve this horrible sickness!"Which of the following responses should t

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ATI RN MENTAL HEALTH ONLINE PRACTICE 2019 B EXAM WITH RATIONALE • A nurse is caring for an older adult client who begins to cry and states, " I knew God would punish me and I deserve this horrible sickness!"Which of the following responses should the nurse make? "Let's talk about what is upsetting you" A nurse on a mental health unit observes a client who has acute mania hit another client.Which of the following actions should the nurse take first? c. call for a team of staff members to help with the situation RATIONALE 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 themselves or others. • A nurse in a providers office is interviewing an older adult client. Which of the following actions should the nurse plan to take? Use a screening tool to evaluate the client for depression RATIONALE Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping. • 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. • The nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? Tooth erosion A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting. • Nurse in mental health facility teaching newly licensed nurse of mechanical restraints. Understands teaching? Apply restraints when other means have failed RATIONALE According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints • Increased risk for depression? a. married b. promotion c. has COPD

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