Mental Health ATI Chapter 1

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A."To assess cognitive ability, I should ask the client to count backward by 7." B."To assess affect, I should observe the client's facial expression." C."To assess language ability, I should instruct the client to write a sentence." D."To assess remote memory, I should have the client repeat a list of objects." - D.CORRECT: This statement requires further teaching. Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory. A.INCORRECT: This statement does not require further teaching. Counting backward by 7 is an appropriate technique to assess a client's cognitive ability. B.INCORRECT: This statement does not require further teaching. Observing a client's facial expression is appropriate when assessing affect. C.INCORRECT: This statement does not require further teaching. Writing a sentence is an indication of language ability. A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to include as a psychobiological intervention? A.Assist the client with systematic desensitization therapy. B.Teach the client appropriate coping mechanisms. C.Assess the client for comorbid health conditions. D.Monitor the client for adverse effects of medications. - D.CORRECT: Monitoring for adverse effects of medications is an example of a psychobiological intervention. A.INCORRECT: Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention. B.INCORRECT: Teaching appropriate coping mechanisms is a counseling or health teaching, rather than a psychobiological intervention. C.INCORRECT: Assessing for comorbid health conditions is health promotion and maintenance, rather than a psychobiological, intervention. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action? A.Respect the client's need for personal space. B.Identify the client's perception of her mental health status. C.Include the client's family in the interview. D.Teach the client about her current mental health disorder - B.CORRECT: Assessment is the priority action when taking the nursing process approach to client care. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history. A.INCORRECT: It is appropriate to respect the client's need for personal space. However, it is not the highest priority action when taking the nursing process approach to client care. C.INCORRECT: If the client wishes, it is appropriate to include the client's family in the interview. However, it is not the highest priority action when taking the nursing process approach to client care. D.INCORRECT: It is appropriate to teach the client about her disorder. However, it is not the highest priority action when taking the nursing process approach to client care. A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following is an expected finding? A.The client arouses briefly in response to a sternal rub. B.The client has a Glasgow Coma Scale score less than 7. C.The client exhibits decorticate rigidity. D.The client is alert but disoriented to time and place. - A.CORRECT: A client who is stuporous requires vigorous or painful stimuli to elicit a response B.INCORRECT: A GCS score of less than 7 indicates a comatose, rather than stuporous, level of consciousness. C.INCORRECT: Abnormal posturing is associated with a comatose, rather than stuporous, level of consciousness. D.INCORRECT: A client who is stuporous is not alert A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following is appropriate to include in the discussion? (Select all that apply.) A.The DSM-5 is used to identify mental health disorders. B.The DSM-5 establishes diagnostic criteria. C.The DSM-5 indicates recommended pharmacological treatment. D.The DSM-5 assists nurses in planning care. E.The DSM-5 indicates expected assessment findings - A.CORRECT: The DSM-5 is used as a diagnostic tool to identify mental health diagnoses. B.CORRECT: The DSM-5 establishes diagnostic criteria for mental health disorders. D.CORRECT: Nurses use the DSM-5 to plan, implement, and evaluate care. E.CORRECT: The DSM-5 identifies expected findings for mental health disorders C.INCORRECT: The DSM-5 is a diagnostic tool for the diagnosis of mental health disorders but does not indicate pharmacological treatment A nurse is using therapeutic communication while counseling a client who has a mental health disorder. A.Topic Descriptor: Define therapeutic communication. B.Underlying Principles: Identify the characteristics of therapeutic communication. C.Underlying Principles: Identify at least three essential components of therapeutic communication. D.Nursing Interventions: Identify at least three specific therapeutic communication techniques - A.Topic Descriptor: Therapeutic communication is the purposeful use of communication to build and maintain helping relationships with clients, families, and significant others. B.Underlying Principles: Characteristics of therapeutic communication ●Client-centered ●Purposeful, planned, and goal-directed C.Underlying Principles: Essential components of therapeutic communication ●Plan for and allow adequate time for communication. ●Demonstrate active listening. ●Demonstrate a caring attitude. ●Be honest. ●Establish trust. ●Demonstrate empathy. ●Have a nonjudgmental attitude. D.Nursing Interventions ●Silence ●Open-ended questions ●Clarifying techniques, such as restating, reflecting, paraphrasing, and exploring ●Offering general leads or broad opening statements ●Showing acceptance and recognition ●Focusing ●Asking questions ●Giving information ●Presenting reality ●Summarizing ●Offering self Which is not an organization that set up the provision of care for clients in a mental health care setting? 1. American Nurses Association (ANA) 2. American Psychiatric Nurses Association 3. National Mental Health Nursing Association 4. International Society of Psychiatric Mental Health Nurses - 3 In addition to the nursing process, which aspects of the holistic approach should nurses working in mental health settings use (select all that apply): 1. biological 2. social 3. physical 4. psychological 5. spiritual 6. sexual - 1, 2, 4, 5 What are the four methods used to assess clients in a mental health care setting? - observations, interviewing, physical examination, collaboration (COPI) Which is not part of the psychosocial history of a patient that occurs during the assessment of someones mental health? 1. patients perception of health 2. patients leisure activities 3. patients health insurance 4. substance abuse and stress level 5. cultural beliefs 6. spiritual beliefs 7. economic status - 3, 5, 6, 7 Level of consciousness, physical appearance, behavior, cognitive and intellectual abilities are all aspects of which mental health assessment tool? - Mental Status Examinations (MSE) mneumonic MSE = LOC PE & cogntion and intelligence T/F When assessing LOC, when a client is in a stupor, the client does not respond to vigorous or painful stimuli (such as pinching a tendon or rubbing the sternum) - False, in a stupor the patient will respond to these stimuli The stupor likes pain to respond T/F When a client is in a stupor, they may not be able to respond verbally. - True A comatose patient has ________ rigidity when there is flexion and internal rotation of upper-extremity joints and legs. 1. decorticate 2. decerebrate - decorticate, arms in tight A comatose patient has ________ rigidity when there is neck and elbow extension, wrist and finger flexion. 1. decorticate 2. decerebrate - decerebrate, arms out to side cere is like cerebrum, imagine arms out and brain on the end.. also the brain is close to the neck Fill in the blank regarding behavior: ________ provides information about the emotion that a client is feeling whereas _______ is an objective expression, such as a lack of facial expression - mood, affect T/F Remote memory asks the client to state a fact from their past that is verifiable, such as a birth date - TRUE When assessing a clients cognitive abilities, what is the following question an example of? "What would you do if there were a fire in your room?" 1. cliche interpretation 2. ability to calculate 3. ability to think abstractly 4. judgement based on hypothetical question. - 4 One standardized screening tool is the mini-mental status exam. It is used to objectively assess a clients cognitive ability by assessing the following (select all that apply): 1. orientation to time and space 2. attention span 3. affect and mood 4. ability to calculate by counting backwards from 7 5. registration and recalling of objects 6. cliche interpretation 7. language (names of objects, following commands, and ability to write) - 1, 2, 4, 5 and 7 In the Glascow Coma Scale (eye, verbal and motor response is evaluated), a score of ____ indicates a patient is awake and alert and a score of ___ or less indicates that a client is a coma. - 15, 7 T/F Factors contributing to delayed treatment in children include lack of ability of the child to describe what is happening and a wide variety of developmental norms - True What does the acronym HEEADDSS stand for in the psychosocial assessment developed for adolescents? - Home, Education Employment, Activities, Drugs, Depression Suicide, Savagery Which is not a standardized assessment tool for the older adult population? 1. Geriatric Depression Scale (short form) 2. Michigan Alcoholism Screening Test 3. Mini-Mental Status Exam 4. Pain Assessment 5. These are all approved for the older adult population - 5 Circle the appropriate response. When conducting an assessment with an older adult client, use a public/private, quiet space with adequate lighting. - private Circle the appropriate response. When conducting an assessment with an older adult client, stand or sit above/at eye level to conduct the interview - at eye level Circle the appropriate response. When conducting an assessment with an older adult client, you should/shouldn't use touch to communicate caring. - should T/F You should always use an older clients surname and formal title when communicating with them. - False, make an introduction and determine the clients name preference. T/F You should never including an older patients family in an assessment - False, include the family and significant others as necessary