VATI ATI MENTAL HEALTH TEST
1. A nurse is planning care for a client following a suicide attempt. Which of
the following interventions should the nurse include in the plan?
Check on the client every 30 min while they are in their room.
The nurse should initiate continuous one-to-one nursing observation,
including when the client is in their room.
Request that a family member bring personal hygiene items from home.
The nurse should not allow any items that can potentially be used to cause
self-harm, such as personal hygiene items brought from home.
Provide the client with plastic eating utensils.
MY ANSWER
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.
Keep the client's door closed at night.
Due to the risk of suicide, the nurse should always keep the client's door
open and unlocked to allow for constant observation.
2.
A nurse is performing an admission assessment for a client who appears
withdrawn and fearful.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.
Determine coping strategies that the client has used in the past.
MY ANSWER
The nurse should determine coping strategies that the client has used in the
past during the working phase of the nurse-client relationship. However,
evidence-based practice indicates that the nurse should take another action
first.
Assist the client in facilitating a change in behavior.
The nurse should assist the client with a behavioral change during the
working phase of the nurse-client relationship. However, evidence-based
practice indicates that the nurse should take another action first.
Introduce the client to other clients in the day room.
The nurse should introduce the client to other clients in the day room to help
the client interact with others during the working phase of the nurse-client
relationship. However, evidence-based practice indicates that the nurse
should take another action first.
3. 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 should ask your provider that question."
This response by the nurse does not address the client's question and can
invalidate the client's concerns.
"I wouldn't worry about any permanent damage you might have caused right
now."
,This response by the nurse is giving false reassurance, which indicates to the
client that there is no cause to worry and might cause the client to stop
sharing feelings.
"Why do you feel like you have damaged your body?"
This response by the nurse is asking a "why" question, which implies
criticism and often makes the client feel defensive.
"You're afraid you have caused physical injury to yourself?"
MY ANSWER
This response by the nurse is 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.
4. A nurse is caring for a client following a fire that destroyed her home and
killed one of 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?
"How are you feeling at this time?"
Although the nurse should assist the client by identifying her feelings, the
nurse should ask another question first.
"Is there someone I can call to be with you now?"
Although the nurse should assist the client by asking about individuals who
can provide emotional support, the nurse should ask another question first.
"Can you tell me what you have done in the past when going through a
difficult time?"
Although the nurse should assist the client by identifying past coping
mechanisms, the nurse should ask another question first.
"Have you thought of harming yourself?"
, MY ANSWER
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.
5.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 priority for the nurse to report to the provider?
Lithium level 0.8 mEq/L
The client's lithium level is within the expected reference range of 0.4 to 1.3
mEq/L. Toxic effects occur at 1.5 mEq/L and higher. The nurse should report
this level to the provider, because it is important for the provider to consider
when prescribing lithium; however, another laboratory value is the priority to
report.
Serum creatinine 2.1 mg/dL
MY ANSWER
The client's serum creatinine level is above the expected reference ranges of
0.5 to 1 mg/dL for young adult females and 0.6 to 1.2 mg/dL for young adult
males. 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 client's lithium dosage
might need to be modified based on this laboratory value and the provider
will need to determine the cause of the client's increased creatinine level.
Causes 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.
Serum sodium 141 mEq/L
The client's serum sodium level is within the expected reference range of
136 to 145 mEq/L. The nurse should report this level to the provider because
1. A nurse is planning care for a client following a suicide attempt. Which of
the following interventions should the nurse include in the plan?
Check on the client every 30 min while they are in their room.
The nurse should initiate continuous one-to-one nursing observation,
including when the client is in their room.
Request that a family member bring personal hygiene items from home.
The nurse should not allow any items that can potentially be used to cause
self-harm, such as personal hygiene items brought from home.
Provide the client with plastic eating utensils.
MY ANSWER
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.
Keep the client's door closed at night.
Due to the risk of suicide, the nurse should always keep the client's door
open and unlocked to allow for constant observation.
2.
A nurse is performing an admission assessment for a client who appears
withdrawn and 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.
Determine coping strategies that the client has used in the past.
MY ANSWER
The nurse should determine coping strategies that the client has used in the
past during the working phase of the nurse-client relationship. However,
evidence-based practice indicates that the nurse should take another action
first.
Assist the client in facilitating a change in behavior.
The nurse should assist the client with a behavioral change during the
working phase of the nurse-client relationship. However, evidence-based
practice indicates that the nurse should take another action first.
Introduce the client to other clients in the day room.
The nurse should introduce the client to other clients in the day room to help
the client interact with others during the working phase of the nurse-client
relationship. However, evidence-based practice indicates that the nurse
should take another action first.
3. 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 should ask your provider that question."
This response by the nurse does not address the client's question and can
invalidate the client's concerns.
"I wouldn't worry about any permanent damage you might have caused right
now."
,This response by the nurse is giving false reassurance, which indicates to the
client that there is no cause to worry and might cause the client to stop
sharing feelings.
"Why do you feel like you have damaged your body?"
This response by the nurse is asking a "why" question, which implies
criticism and often makes the client feel defensive.
"You're afraid you have caused physical injury to yourself?"
MY ANSWER
This response by the nurse is 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.
4. A nurse is caring for a client following a fire that destroyed her home and
killed one of 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?
"How are you feeling at this time?"
Although the nurse should assist the client by identifying her feelings, the
nurse should ask another question first.
"Is there someone I can call to be with you now?"
Although the nurse should assist the client by asking about individuals who
can provide emotional support, the nurse should ask another question first.
"Can you tell me what you have done in the past when going through a
difficult time?"
Although the nurse should assist the client by identifying past coping
mechanisms, the nurse should ask another question first.
"Have you thought of harming yourself?"
, MY ANSWER
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.
5.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 priority for the nurse to report to the provider?
Lithium level 0.8 mEq/L
The client's lithium level is within the expected reference range of 0.4 to 1.3
mEq/L. Toxic effects occur at 1.5 mEq/L and higher. The nurse should report
this level to the provider, because it is important for the provider to consider
when prescribing lithium; however, another laboratory value is the priority to
report.
Serum creatinine 2.1 mg/dL
MY ANSWER
The client's serum creatinine level is above the expected reference ranges of
0.5 to 1 mg/dL for young adult females and 0.6 to 1.2 mg/dL for young adult
males. 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 client's lithium dosage
might need to be modified based on this laboratory value and the provider
will need to determine the cause of the client's increased creatinine level.
Causes 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.
Serum sodium 141 mEq/L
The client's serum sodium level is within the expected reference range of
136 to 145 mEq/L. The nurse should report this level to the provider because
