ATI Mental Health – Flashcards
Unlock all answers in this set
Unlock answersquestion
A nurse in an emergency department is assessing a client for a suspected cocaine intoxication. Which of the following findings should the nurse expect?
answer
Dilated pupils
question
A nurse is caring for a group of clients. The nurse should recognized that which of the following clients is at risk for a vitamin 56 deficiency?
answer
a client who has chronic alcohol use disorder
question
A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps out and runs out of the room yelling,"you are all making fun of me the should identify this behavior as which of the following characteristics of schizophrenia?
answer
ideas of reference
question
a nurse is caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
answer
I see you have done some grooming today
question
a nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
answer
a client who has been taking amitriptyline for 3 months for depression
question
a nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from post traumatic stress disorder if the client which of the following statements?
answer
in my dreams, all i can see are the wounded reaching out and trying to grab me
question
A nurse on a crisis hotline is speaking to a client who says, "i just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
answer
I'm glad you called, and I want to send an ambulance to help you
question
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
answer
ask the client to describe the situation
question
A nurse is caring for a client who has schizophrenia and tells the nurse, "they lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?
answer
You seem to be having very frightening thoughts
question
A nurse at a college campus mental health counseling center is caring for a student who just failed examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?
answer
Projection
question
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate?
answer
I don't see any bugs, but you seem very frightening
question
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?
answer
Leaves the child's room exactly as it was before the loss
question
A nurse is caring for a client who has severe manifestations of schizophrenia and is medication PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?
answer
Dysrhuthmias
question
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
answer
Talk the client through talks one step at a time
question
A nurse in a mental health facility is planning care for a client who has obsessive compulsive disorder and is newly admitted to the unit.
answer
plan the client's schedule to allow time for rituals
question
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
answer
Tell me what is concerning you
question
a nurse is caring for a client who has borderline personality disorder. As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning
answer
I don't like it when you address me with that tone of voice
question
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received telephone call that was upsetting
answer
Walk with the client at a gradually slower pace
question
A client becomes very dejected and states, "No really cares what happens to me. Life isn't worth living anymore." Which of the following responses should
answer
I care about you, and i am concerned that you feel so
question
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should
answer
Forgetfulness
question
A nurse at a walk-in mental health cliic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?
answer
Threatening behavior
question
A nurse in an cute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.o mEq/l. which of the following actions should the nurse take?
answer
Administer the morning dose of lithium
question
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
answer
I plan to sit on a park bench for a few minutes each day
question
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
answer
Ask the client to agree to talk to a nurse whenever she feels the urge to exercise
question
A nurse is caring for a client who is extremely suspicious of the nursing staff and clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
answer
Adopt a neutral attitude when providing care
question
A nurse is providing teaching for a client who has binge eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
answer
I will take my dose of orlistat every morning an hour before breakfast
question
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with will be discharged with a prescription for lithium. The nurses's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity
answer
experiencing diarrhea
question
A male nurse is assigned to care for a female client who has admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
answer
i can review the assignment and arrange for a female nurse to care for you
question
A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?
answer
Explain that antidepressants often take several weeks to be fully effective
question
a nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy. The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make?
answer
The main side effects are temporary, and may include mild confusion, a headache, and short term memory loss
question
A nurse is caring for a client who is dying. the client says, "my mother died in the hospital, but i did not get there before she died.' Which of the following statements should the nurse make?
answer
I wonder if you are fearful of dying alone
question
A school nurse is talking with a 13 year old female at her annual health screening visit. Which of the following comments made by the adolescent should be the nurses priority to address?
answer
None of the kids at this school like me, and i dont like them either
question
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurses's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
answer
You must be very upset about something
question
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tar dive dyskinesia when the client exhibits which of the following?
answer
tongue thrusting and lip smacking Facial grimacing and eye blinking is correct involuntary pelvic rocking and hip thrusting movements
question
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72- hr hold is over for which of the following conditions?
answer
The client is a danger to herself or others
question
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "i'm feeling really down and don't want to talk to anyone right now.' Which of the following responses should the nurse make?
answer
I'll just sit here with you for a few minutes then
question
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
answer
It sounds like you're having a difficult time
question
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
answer
A private room in a quiet location on the unit
question
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
answer
Providing for adequate hydration and rest
question
A nurse in an emergency department is assessing a client who has been talking haloperidol for 3 months. The client has a temp of 37.5 C, blood pressure of 150/11- mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
answer
Neuroleptic malignant syndrome
question
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. which of the following initial actions should the nurse take?
answer
Talk to the client and identify the specific limits that are required of the client's behavior
question
A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?
answer
Determine the clients need for assistance with grooming
question
A nurse is admitting a client who has experienced a weight loss of 11kg in the past 3 months.
answer
Identify the clients nutritional status
question
discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium
answer
The client runs 4 miles outdoors every afternoon
question
diagnosed with obsessive compulsive disorder and is constantly picking up after others in the day room,
answer
Decrease anxiety to a tolerable level
question
A nurse is caring fora client who is depressed and refuses to participate in group therapy or perform activities of daily. Which of the following statements should the nurse make to the client?
answer
I will assist you in getting out of bed and getting dressed
question
a nurse asks a client who is suicidal to make a safety contract, but the client declines.
answer
Assign a staff member to stay with the client at all times
question
A nurse is caring for a client who has bipolar disorder and new prescription for valproate.
answer
Liver function test must be monitored
question
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
answer
Walking with the nurse in the courtyard
