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ATI Capstone Mental Health A nurse in an acute care facility is assisting with the admission of an older adult client who has late stage Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his partner. Which of the following actions should the nurse take first? ✔✔Ask the partner to talk about his difficulties in caring for the client. The first action the nurse should take, using the nursing process priority framework, is to collect data regarding the partner's ability to take care of the client. A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates the medications is effective? ✔✔Decrease in urge to smoke Bupropion is an antidepressant that is also used for smoking cessation. A nurse is evaluating the outcome for a client who has depression following the death of his wife 3 months ago. Which of the following client statements indicates a need for further intervention? ✔✔"I just don't feel like eating because I never like to eat alone." At risk for malnutrition and injury. A nurse in a long-term care setting is caring for a client who has Alzheimer's disease. The client states, "I just came back from a hard day's work in my office." The nurse should identify this statement is an example of which of the following coping mechanisms? ✔✔Confabulation Confabulation is the creation of information which is untrue to fill in gaps in memory and to protect self-esteem in clients who have dementia. A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse- client relationship? ✔✔Use active listening when with the client. The nurse should use active listening to establish presence with the client. presence involves eye contact, body language, voice tone, listening, and reflection to convay openness and understanding. A nurse is assessing a client in the emergency department who drank alcohol while taking disulfiram. The client states, "The nurse told me not to drink when taking the medication. I am just a social drinker. I didn't realize that having just one drink with my friends would cause such
a problem." Which of the following defense mechanisms is the client demonstrating? ✔✔Rationalization The client is demonstrating rationalization when he creates reasonable and acceptable explanations for unacceptable behavior. The client is using rationalization asa defense mechanisms to justify why he had just one drink. Even though the nurse told him not to drink alcohol. A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium? ✔✔A client asks when family members will be arriving after visiting 1 hr earlier. Delirium is characterized by a change in cognition that occurs over a short period of time. It always results from secondary physiological condition, ( infection, surgery, prolonged hospitalization, hypoxia, fever, medication) and is a transient disorder. Although delirium can occur at any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome" A nurse is collecting data from a client newly admitted for anorexia nervousa. Which of the following findings should the nurse expect? ✔✔Amenorrhea The nurse should expect the client to report amenorrhea due to low body weight. A nurse is collecting data from a client who has bipolar disorder with main. Which of the following findings is the nurse's priority? ✔✔The client paces in the hallway during the day and most of the night. When using Maslow's hierarchy of needs, the nurse determines that the priority findings is the client's physiological need for rest and food. Nonstop activity is an emergency situation for a client who has mania, since the client might go for long periods without eating or sleep. A nurse is preparing to assist with the care of a client of a client who is undergo electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? SATA ✔✔- Electroencephalogram (EEG) monitor. The provider will monitor the client's brainwave patterns during the procedure.
- Oxygen saturation monitor The client requires continuous oxygen saturation monitoring because she will receive a short- acting barbiturate to induce sleep and a muscle-paralyzing agent to prevent muscle distress and injury.
- Electrocardiogram (ECG) monitor.
A nurse is caring for an older adult client who is scheduled for surgery. The client becomes upset when the nurse asks her to remove her dentures prior to the surgery. Which of the following is a therapeutic response by the nurse? ✔✔" You seem worried. Are you concerned someone may see you without your teeth?" The nurse uses two therapeutic communication tools in this response. One is empathy, which is shown by focusing on the client's feelings. The other is validation/clarification, in which the nurse seeks to validate the reason for the client's feelings. A nurse is talking with a client who has schizophrenia. Suddenly the client states, "Im tightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate? ✔✔"What are the voices telling you to do?" This statement recognizes the risk involved with a command hallucination an asks there client directly about the hallucination. This is a therapeutic approach to communicating with a client who is experiencing a hallucination. A nurse is collecting data from a client who has a major depressive disorder (MDD). Which of the following findings should the nurse expect? ✔✔Significant change in weight A signifiant change in weight, either loss or gain, is an expected finding of MDD. A nurse is reinforcing teaching with a client about a new prescription for lithium. Which of the following statements should the nurse include in the teaching? ✔✔"We will need to check your lithium levels in the next 3 to 5 days." Lithium is prescribed to treat bipolar disorder. The medications has a narrow therapeutic range and establishing a therapeutic lithium level is an essential component of care. It is recommended to check lithium levels within the first 5 days of beginning of treatment and possibly twice weekly until a maintenance dosage has been reached. Lithium levels are checked about every 3 months during maintenance therapy when lithium levels have stabilized. A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse. Which of the following comorbidities should the nurse include in the discussion? SATA ✔✔- Anxiety Anxiety is a comordid condition common in clients who have an eating disorder.
- Obsessive-compulsive Disorder OCD is a comorbid condition common in clients who have an eating disorder, especially anorexia nervosa.
- Depression
Depression is a comorbid condition common in clients who have an eating disorder. A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following statements by the client indicates that the client is in the denial phase of the grief process? ✔✔"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." The Five stages of Grief may not be experienced in order, and the length of each stage will vary from person to person. A nurse is discussing restraint with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client? ✔✔Continued self-destructive behavior A nurse my use mechanical restraints for a client who presents a specific danger to themselves or others. The nurse must follow all facility policies, such as documentation of the behavior that led up to the use of restraints and other interventions the staff used prior to the restraints. A nurse is caring for a client whose wife died 6 months ago. For which of the following findings should the nurse monitor to identify a maladaptive grieving response? ✔✔Disturbed self-esteem A client who has disturbed self-esteem, such as feeling of worthlessness, is likely having a maladaptive grieving response, which can precipitate depression. A client who has a femur fracture states, "I cant stay in this bed any longer. I need to get home so I can take care of my family." The nurse response by saying, "You have talked about your family. Can you tell me more about your specific concerns?" Which of the following therapeutic communications techniques is the nurse using? ✔✔Focusing The nurse's open-ended statement is a means of focusing on the problem and obtaining more information about the client's concerns, which helps the nurse to identify issues and concerns clearly. A nurse is caring for a client who witnessed her brother's homicide and has post traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? ✔✔The client is easily startled by loud voices. A hyperactive startle reflex (hyper vigilance) due to constant anxiety, is a common finding in client who have PTSD. A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first? ✔✔Remain with the client.
This demonstrates therapeutic communication. During the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and advocacy. A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? "The ritualistic behavior provides sexual satisfaction." "The client performs ritualistic behavior to boost self-esteem." "The ritualistic behavior temporarily relieves anxiety." "The client performs ritualistic behavior to decrease feelings of shame." ✔✔"The ritualistic behavior temporarily relieves anxiety."; Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to obsessions. A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the following information should the nurse include in the teaching? "Use a reliable form of contraception while taking this medication." "If a dose is missed, double the next dose of medication." "This medication may increase your blood pressure." "Do not eat aged cheeses while taking this medication." ✔✔"Use a reliable form of contraception while taking this medication."; Alprazolam is a pregnancy category D medication, indicating it causes definitive adverse effects on a fetus. A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching? "You really shouldn't change the schedule we established here in the facility." "Let's work together to devise a time schedule that is convenient for you on a daily basis." "We'll have to talk to your provider about switching to an alternative schedule." "It doesn't really matter what time you take your medications as long as you don't skip any doses." ✔✔"Let's work together to devise a time schedule that is convenient for you on a daily basis.";
This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the client's needs at this time. A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "you are all making fun of me." Which of the ff behaviors is this client displaying? Grandeur Flight of ideas Erotomania Ideas of reference ✔✔Ideas of reference; Ideas of reference occur when a client believes that conversations of others always concern him and that others are ridiculing him. A nurse is teaching a client who has a new prescription for paroxetine. Which of the following statements by the client indicates an understanding of the teaching? "I may experience an increased desire to have sex." "My blood pressure may increase." "I may notice excess saliva." "I may not feel like eating as much." ✔✔"I may not feel like eating as much."; Anorexia and a decreased appetite are adverse effects of paroxetine. A nurse is caring for a client on an acute care mental health unit. Client has a history of bipolar disorder and self-injurious behavior. 1330: Client pacing rapidly across their room and shouting loudly at nursing staff. Client appears agitated. Verbal de-escalation measures implemented. Client returned to their bed and is refusing to talk or make eye contact. 1345: Client displays self-injurious behavior by attempting to cut themselves with plastic utensils from their lunch tray. Complete the following sentence by using the lists of options. The nurse should _______________, followed by ____________________. ✔✔Assist the charge nurse in placing the client in restraints; Monitoring the client's behavior for their ability to be reintegrated into unit activities is correct. De-escalation techniques failed to help the client and the client is now attempting to harm themselves. In emergency situations, such as client self-harm, the charge nurse is allowed to place the client in restraints with assistance of the nursing staff as needed.
Contact the laboratory to obtain a blood sample is correct. A blood sample allows for a blood alcohol level test to be performed.Prepare the client for a CT scan is correct. A CT scan or other neurological tests is performed to rule out brain injury or head trauma.Check the client's pupil reactivity is correct. Checking for pupil reactivity provides information about a client's neurological status.Obtain a urine specimen is correct. A urine specimen is needed to perform a urine toxicology screen.Perform a developmental screening test is incorrect. A developmental screening test is appropriate when needing information about a child or adolescent's maturational or developmental level. A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia. The available medication is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose? ✔✔2 tablets A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving? Leaves the child's room exactly as it was before the loss Volunteers at a local children's hospital Talks about the child in the past tense Visits the child's grave every week after worship services ✔✔Leaves the child's room exactly as it was before the loss; Grieving becomes dysfunctional when the client is unable to resume regular activities of daily living or experience emotions other than sadness or depression. An example of dysfunctional grieving is making the loved one's room a shrine for more than a year. A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which fo the following interventions is the nurse's priority? Recommend that the partner place the client in a long-term care facility. Suggest that the partner see a counselor to help him cope with his exhaustion. Ask the partner to talk about his difficulties in caring for the client. Tell the partner to call a family meeting to get help. ✔✔Ask the partner to talk about his difficulties in caring for the client; The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife. A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
Disclose some personal information to the client to demonstrate approachability. Wait for the client to initiate interaction. Approach the client frequently throughout the day for brief interactions. Adopt a neutral attitude when providing care. ✔✔Adopt a neutral attitude when providing care; To promote a therapeutic relationship, the nurse should use a neutral, nonthreatening attitude during care and communication. A nurse in an outpatient mental health clinic is caring for a client who has an eating disorder.Which of the following findings in the client's medical record indicates the client has bulimia nervosa? 1400: BMI 20. Erosion of teeth, numerous dental caries Client reports overeating with subsequent episodes of induced vomiting every weekday evening following work; takes over-the-counter laxative and diuretic medication every morning. Reports good relationship with family and friends. Denies substance use. Reports doing little exercise except on weekends. 1500: 12 - lead ECG Sinus rhythm with frequent premature ventricular contractions (PVCs), heart rate 72/min 1600: Potassium 3.2 mEq/L ✔✔Erosion of teeth, numerous dental caries Client reports overeating with subsequent episodes of induced vomiting every weekday evening following work Takes over-the-counter laxative and diuretic medication every morning. Sinus rhythm with frequent premature ventricular contractions (PVCs), heart rate 72/min Potassium 3.2 mEq/L BMI 20.1 is correct. Clients who have bulimia nervosa often have a BMI within the expected reference range. Erosion of teeth, numerous dental caries is correct. Erosion of teeth, numerous dental caries, and parotid swelling are manifestations of bulimia nervosa that result from frequent induced vomiting. Overeating with subsequent episodes of induced vomiting every weekday evening following work is correct. Clients who have bulimia nervosa eat excessive amounts of food in a short period of time and then perform compensatory behaviors, such as inducing vomiting. Taking over-the-counter laxative and diuretic medication every morning is correct. Clients who have bulimia nervosa often misuse laxatives and diuretics to rid the body of food and liquid.
A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A room adjacent to the nursing station A room without a window A room with dim lighting A room containing personal belongings ✔✔A room containing personal belongings; A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment. A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? Hyperactive bowel sounds Bradycardia Hypertension Dental erosion ✔✔Bradycardia; Complications of anorexia include bradycardia and muscle wasting. A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take? Inform the client of consequences. Speak slowly in a low, calm voice. Forbid the client from speaking in an abusive manner. Remain a distance of 1 ft away from the client. ✔✔Speak slowly in a low, calm voice; Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and caring. The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects that the client is suffering from post-traumatic stress disorder if the client makes which of the following statements? "I check any room I enter because the enemy is still after me and could be hiding anywhere." "My child was born with a birth defect due to an exposure I had overseas." "I killed four enemy soldiers with my bare hands and saved my entire battalion." "In my dreams, all I can see are the wounded reaching out and trying to grab me." ✔✔"In my dreams, all I can see are the wounded reaching out and trying to grab me.";
Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. This client's statement about haunting dreams is typical of a client who has PTSD. A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care? Discourage rest periods during the daytime. Instruct family to avoid visiting during mealtimes. Offer three or four large meals daily. Give the client extra time to communicate needs. ✔✔Give the client extra time to communicate needs; Clients who have vegetative signs of depression have slowed thought processes and might take extra time to reply to questions or to verbalize thoughts. The nurse should display patience and give the client extra time to communicate. A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 mos. Which of the following interventions should the nurse take? Make a contract with the client not to drive over the speed limit. Call the local police and alert them to the client's car license plate number and the make and model of her car. Ask the client to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. Inform the client that she cannot drink and drive. ✔✔Make a contract with the client not to drive over the speed limit; A behavior contract is appropriate to identify the expected behavior and consequences. The client, by signing the contract, assumes responsibility for her behavior. A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make? "You should be aware that excessive sleeping is an early sign of relapse." "Relapse is an indication that you are not taking your medications properly." "You should keep your provider's and therapist's number with you." "Taking an additional dose of medication is appropriate as soon as signs of relapse appear." ✔✔"You should keep your provider's and therapist's number with you.";
Shuffling gait Constant tapping of feet when sitting Sudden onset of high fever Twisting tongue movements ✔✔Twisting tongue movements; Twisting tongue movement, tics, sudden involuntary jerking movements of the extremities, and other findings occur in TD. The nurse should notify the provider of these findings since treatment includes reducing dosage of antipsychotic medications or perhaps changing to a second-general antipsychotic medication. A nurse is providing discharge teachings to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? The client runs 4 miles outdoors every afternoon. The client drinks 2 liters of liquids daily. The client eats 2 to 3 gm of sodium-containing foods daily. The client eats foods high in tyramine. ✔✔The client runs 4 miles outdoors every afternoon; Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics. A nurse is initiating a plan of care for a client who has been admitted to a medical unit for acute care of manifestations of anorexia nervosa. Which of the following interventions should the nurse include in the plan? Allow the client to exercise freely. Assess for weekly weight gain of at least 0.9 kg (2 lb) per week. Allow the client to eat meals privately in their room. Sit with the client for 30 min following meals. ✔✔Assess for weekly weight gain of at least 0. kg (2 lb) per week; The nurse should plan to assess the client's weight for a gain of 0.9 to 1.4 kg (2 to 3 lb) per week. Weight gain of 2.3 kg (5 lb) or more in a week can cause pulmonary edema. If the client does not gain adequate weight, they might need additional calories from supplements or tube feedings. A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I think it is going to hurt so I have changed my mind." Which of the following responses should the nurse make?
"Your provider wouldn't have requested this if it wasn't necessary." "It is too late to cancel the procedure now." "Don't worry. You will feel so much better afterwards." "Tell me your concerns about the procedure." ✔✔"Tell me your concerns about the procedure."; The nurse should encourage the client to express their concerns and fears about the procedure by using open-ended statements. If the client still wants to cancel treatment, the nurse should inform the client that they have the right to refuse treatment at any time. Even if the client changes their mind after the procedure has begun, the client can request to stop the procedure. A nurse is caring for a client who has schizophrenia and was admitted involuntarily. The client states "I don't want to be here. Which of the following statements should the nurse make? "You have the right to legal counsel if you wish." "You have the right to leave the facility against medical advice." "You will need to provide a written explanation about why you wish to leave." "You will need a letter from an attorney stating your decision to discontinue treatment." ✔✔"You have the right to legal counsel if you wish."; The nurse should inform the client that they have a right to request legal counsel to review their case regarding their involuntary admission and their desire to be discharged. A nurse overhears a visitor ask an assistive personnel (AP), "Can you tell me why my neighbor was admitted?" The AP begins to look up the information. Which of the following actions should the nurse take? Ask to speak with the AP privately. Tell the AP to provide the information. Tell the visitor to speak with the client's provider. Instruct the visitor to fill out an information request form. ✔✔Ask to speak with the AP privately; The nurse should stop the AP from disclosing the client's private information and should speak with them privately. The nurse should inform the AP that the client must authorize who and what personal health information is to be shared. Providing this information to the visitor without the client's consent is a breach of the client's confidentiality. A nurse is assisting in obtaining informed consent from a client who is scheduled for electroconvulsive therapy. Which of the following actions should the nurse take? Ask the client if they understand the procedure. Inform the client of alternative treatments that are available.
Is physically cruel to other children ✔✔Refuses to accept responsibility for actions; A child who has oppositional defiant disorder can exhibit passive-aggressive behaviors, argue with authority figures, refuse to comply with requests from authority figures, deliberately annoy others, and blame others for their mistakes or misbehavior. A nurse is assessing a client who has antisocial personality disorder. Which of the following characteristics should the nurse expect? Lack of remorse Fear of abandonment Suicidal behaviors Chronic feelings of emptiness ✔✔Lack of remorse; Manifestations of antisocial personality disorder include a lack of remorse, a reckless disregard for the safety of one's self and others, and a failure to conform to social norms with respect to lawful behaviors. Clients who have antisocial personality disorder can also be consistently irresponsible, irritable, and aggressive. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first? Encourage the client to discuss the events occurring before the attack. Teach the client relaxation techniques. Tell the client to listen to music. Remain with the client. ✔✔Remain with the client; The nurse should remain with the client during a panic attack. This promotes a feeling of safety and reassurance for the client. A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? Avoid the use of nonverbal gestures to prevent miscommunication. Overlook the client's frustration with communication. Inform the client about scheduled daily activities. Present the client with multiple choices to promote autonomy. ✔✔Inform the client about scheduled daily activities; Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day.
A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client indicates successful use of guided imagery? "I imagine my negative emotions consuming my thoughts." "I imagine solving my problems over and over again." "I imagine myself being overwhelmed during difficult times." "I imagine myself lying on a beach when I start to feel stressed." ✔✔"I imagine myself lying on a beach when I start to feel stressed."; Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery. A nurse is assessing a toddler during a well child visit. Which of the following findings should the nurse identify and report to the provider as an indication of physical maltreatment? Several round burns on the soles of the feet An abrasion on the elbow Two bruises on the right shin in various stages of healing A contusion on the forehead ✔✔Several round burns on the soles of the feet; Although minor injuries are common in toddlers due to their general lack of coordination, the nurse should identify that physical findings such as round burns on the soles of a child's feet can indicate potential physical maltreatment. Burns such as these can be made with a cigarette or a cigar and should alert the nurse to a potential instance of maltreatment that should be reported to the provider. A nurse is caring for a client who becomes agitated while playing a game of cards with other clients. The client stands up, throws the cards on the floor, and says, "I don't want to play anymore." Which of the following actions should the nurse take? Ignore the client's outburst. Whisper reassuring comments in the client's ear. Allow the client to choose another activity. Ask the client to accompany the nurse to another area. ✔✔Ask the client to accompany the nurse to another area; The nurse should ask the client in a calm and nonthreatening manner to walk with them to another area, away from the location of the outburst. Removing the client from the situation will ensure the safety of the other clients as well as deescalate the situation. A nurse is discussing types of crises with a newly licensed nurse. Which of the following experiences should the nurse include as an example of maturational crisis?
