ATI Mental Health Questions – Flashcards
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A nurse enters a clients room and observes that the client is agitated and pacing rapidly. the client looks at the nurse and says back off leave me alone. which of the following statements should the nurse make?
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I demand that you come down now your behavior is unacceptable I will close the door to provide privacy and you can tell me what is bothering you I will give you space if you calm down tell me what is causing you to feel so tense*** I will leave you alone for a few minutes while you try to control yourself
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A nurse is caring for a client who has borderline personality disorder. The nurse enters the clients room and finds the client cutting into his flesh with a paperclip after providing first aid, which of the following actions should the nurse take first
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Encourage the client to discuss feelings about his self injurious behavior during group therapy fill out an incident report for risk management about the client self injurious behavior document the self injurious behavior in his medical record identify the clients feelings that led to the self injurious behavior***
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A nurse is caring for a client who reminds her of a negative person in the past these memories cause the nurse to unconsciously displays negative feelings toward the client the nurse should recognize that she is demonstrating which of the following behaviors
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Suppression countertransference *** transference assertiveness
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A nurse is establishing a therapeutic relationship with a client who has hallucinations which of the following actions should the nurse take during orientation phase
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Identify the clients perception of the reason for therapy *** ask the client to provide a detailed description of the hallucinations assist the client with the development of problem-solving skills explore the clients relationship with family members
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A nurse is planning care for a client who has thoughts of suicide which of the following goals should the nurse include in the clients plan of care
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The client will identify positive aspects of others the client agrees to notify a staff member of thoughts of self harm *** the client will engage an independent diversional activity the client will not verbalize thoughts or feelings related to suicide
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A nurse is caring for a client who has a new diagnosis of colon cancer shortly after the client receives the diagnosis the nurse enters the clients room and the client begins yelling I received terrible care here and no one cares about me the nurse should recognize that the client is demonstrating which of the following defense mechanisms
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Denial displacement *** reaction formation projection
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A nurse is meeting a client following care in the emergency department for an intentional overdose of opioids the client states I feel so alone no one can help me which of the following responses by the nurse is therapeutic
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Lets finish your admission and then talk about your feelings how come you feel that no one can help you when you are receiving help now why do you feel that no one can help you I would like to sit and talk with you***
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A nurse is caring for a client who's adolescent child died in a motor vehicle crash the clients crying inconsolably which of the following actions should the nurse take
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Suggest that the client call the facility Chaplin provided quiet place for the client to be alone stay with the client and allow the client to cry *** express sympathy for the clients loss
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A nurse in a mental health clinic is caring for a client who has bipolar disorder and states I no longer take my medication because I like the feeling of being manic which of the following responses by the nurse is an example of therapeutic communication
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You might feel good now but what about when you get depressed why do you think you like feeling manic you feel better when you don't take your medication? *** what do you think your provider will say about you going off your medication
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A nurse is planning reminiscence therapy for an older adult client The Nurse should identify which of the following goals for the clients therapy
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The client will gain increased self-esteem *** the client will maintain orientation to place and time The client will independently perform ADL the client will achieve optimal sensory stimulation
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A nurse is performing a mental status assessment on an older adult client who has dementia which of the following questions should the nurse ask to assess the clients remote memory
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What year did you graduate from high school *** what is your favorite childhood memory what did you have for supper yesterday what is today's date
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A nurse is counseling a client who seems relaxed initially but then becomes restless and begins wringing his hands the nurse states that the client seems tense. The client agrees, which of the following statements should the nurse make
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Did I say something wrong that made you feel tense do you often feel tense when you were talking to a healthcare provider what were we discussing when you begin to feel uncomfortable *** it is ok to feel nervous during our counseling session's
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A nurse and a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa the client tells the nurse I know my eating binges and vomiting or not normal but I cannot control it which of the following responses should the nurse take
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Why do you think you are experiencing these behaviors of binges and vomiting are other students in your dorm also experiencing this behavior you're feeling helpless about changing this behavior?*** you know you must stop because you are endangering your health
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A nurse is caring for a client at a college mental health counseling center the client received a failing grade in the course and spent the entire counseling session blaming the teacher the nurse should recognize this behavior as an example of which of the following defense mechanisms
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Projection *** dissociation undoing compensation
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I nurse and emergency department is caring for an 18 month old toddler who has fractured femur on the left which of the following statements by the Toddlers parents would cause the nurse to suspect child abuse
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My child fell down the stairs my child was riding a bicycle and fell off *** My child slipped out of the highchair my child climbed up on a chair and it tipped over
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A nurse and a mental health facility is reviewing confidentiality requirements with a newly licensed nurse which of the following statements by the newly licensed nurse indicates an understanding of the information
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I am legally required to notify clients employer about a substance use disorder if a client is involuntarily committed I can discuss information with the clients next of Kin I can discuss the clients treatment with others as long as they're employees of the facility I should keep information private even after clients death***
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A nurse at an acute mental health facilities caring for a client who has acute mania bipolar disorder. At 3 am the client runs to the nurses station and demand to see the provider immediately. which of the following responses should the nurse make?
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Your request is unreasonable we cannot call your provider at three in the morning if you can calm down for five minutes then I will call your provider for you calm down go back to your room and come back in 15 minutes and will talk about how you're feeling you must be very upset about something to want to see a provider in the middle of the night***
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A nurse is caring for a client who has depression and started taking peroxetine one week ago. The client states to the nurse, "my family would be better off without me." which of the following responses should the nurse make
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Why do you feel your family would be better off without you many people feel this way when they're depressed You sound upset are you thinking of hurting yourself*** your medication hasn't started working yet then you'll be feeling differently
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A nurse is conducting a counseling session with a client who has a substance use disorder the client repeatedly ask personal questions about the nurse which of the following actions should the nurse take
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Explain that this time is designated to focus on the client *** answer the personal inquiry questions matter-of-factly tell the client that interested in someone besides himself as an indication of improvement request that the personal question to be asked after the counseling session is over
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A nurse is providing support for the parents of a child who has a new diagnosis of terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first
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Denial *** bargaining anger depression
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A nurse is assessing a client who is experiencing moderate level anxiety which of the following findings should the nurse expect
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The client has a heightened perceptual field The client has difficulty concentrating *** the client reports shortness of breath the client reports a sense of impending doom
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A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant the nurse should identify what statement as the clients priority
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I hate being so helpless I can't even manage my own finances anymore at group therapy today I wanted to leave I didn't feel like being with other people I have it all figured out everything is going to be ok now *** I don't feel like showering I'd rather just stay in bed today
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A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yelled at her son saying quit lying about your father. The nurse should recognize that the client is demonstrating which of the following defense mechanisms
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Denial *** identification introjection sublimation
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A nurse is caring for a client who has alcohol use disorder and is receiving treatment for alcohol withdrawal the client reports hand tremors 12 hours after admission which of the following statements should the nurse make
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The tremors are permanent due to nerve damage caused by chronic alcohol use the tremors will persist for a few days as you are withdrawing from alcohol *** try not to worry about the tremors everyone has these during alcohol withdrawal These tremmors are an indication of seizures that are associated with alcohol withdrawl
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A nurse and a pediatric emergency department is caring for four clients the nurse should suspect possible abuse with which of the following clients
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A 14-month-old toddler who has recently learned to walk and as many bruises on bony prominences is in various stages of healing a nine month old infant who reportedly nearly drowned after climbing into the tub and turning on the water *** a six year old toddler who has a fracture of the tibia and fibula which reportedly occurred while riding a bicycle A three all toddler who has burned in a splash pattern over the face and chest reportedly sustained when a tablecloth was pulled spilling a teapot
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A nurse is assessing a client who has anorexia nervosa the nurse can expect the client to display which of the following characteristics
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Refuses to participate in physical exercise activities possesses feelings of decrease self-worth *** preoccupied with concerns about personal health avoids discussion of food
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The nurse in a mental health clinic is caring for a client who states I think I may have a problem with alcohol which of the following actions should the nurse take first
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Provide the client with information about a 12 step recovery program encourage the client to accept responsibility for his alcohol use teach the client alternate coping mechanisms to use in place of alcohol ask the client to complete a CAGE questionnaire***
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A nurse is administrating an oral sedative to a client who is receiving care following an involuntary admission. The client states I am not taking any more medication. which of the following action should the nurse take
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Administer the medication by another route refer clients refusal to the facilities ethics committee inform the client that due to her involuntary admission she cannot refuse a sedative document the clients refusal of the medication in the medical record***
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A nurse is caring for a client who has a borderline personality disorder. the client has previously identified another nurse as his favorite stating he's the best nurse ever. When the nurse calls in sick which of the following statements indicates that the client is using splitting as a method of coping
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He's the worst nurse that's ever taken care of me *** you're just lying to me he's not really sick he's my favorite nurse and I'm really worried about him if anyone else tries to take care of me I'm going to get really upset
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A nurse is caring for a school-age client who begins wetting after finding out that her parents are getting a divorce. You should identify that the client is exhibiting which of the following defense mechanism
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Regression *** projection repression splitting
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A nurse is caring for a client who attempted suicide and refuses to sign a no suicide contract which of the following actions should the nurse take when implementing suicide precautions
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Assign the client to a private room request that the dietary department provide the client with finger foods place the client on one-to-one observation *** keep the door to the clients room closed
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A nurse received a call from a crisis intervention heartline from a client. which of the following statements can the nurse identify as an overt statement indicating the clients risk for suicide
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Everything will be better soon Soon no one will have to worry about me there's no point in living any longer *** I want to donate my organs to help others
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A nurse is caring for a client who has depression and the client has not come to breakfast and is still in bed. The client states I'm not worth your time leave me alone and go help someone else. which of the following responses should the nurse make
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Many people feel this way when they first start treatment in other words you seem to be saying that you feel unworthy of help*** you'll feel better once you get up and have some breakfast I disagree with you feeling that you're not worth my time
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A nurse is caring for a client who has dementia the client states to the nurse everyone wants to kill me which of the following responses should the nurse make
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Tell me how everyone wants to hurt you you must feel very frightened to think someone wants to hurt you *** no one here wants to kill you Who in particular do you think wants to kill you
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Community mental health nurse is planning strategies to address substance used by adolescents which of the following interventions should the nurse plan as a method of primary prevention
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Offer substance use treatment options for adolescents from low income households encourage the use of random testing for substance use for adolescence participating in extracurricular activities educate high school teachers about how to detect the manifestations of substance use provide a presentation at area high schools on resisting peer pressure for substance use***
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Nurse is preparing to apply restraints on a client who is threatening to harm others and has not responded to less invasive interventions which of the following actions should the nurse plan to take
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obtain a PRN prescription for restraints from the clients provider visually observe the client every 10 minutes until restraints are removed ensure that three fingers can fit between the restraint and the clients wrist document the clients behavior every 15 minutes while restraints are in place***
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A nurse came for a client who has schizophrenia. The client states my internal organs have turned to stone. To document this finding is which of the following types of delusions
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Somatic*** reference persecutory grandiose
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A nurse is completing an initial assessment for an adolescent client who has depression. the nurse should identify which of the following findings is priority
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The client as confrontational with his parents the client is getting D's in his class because he frequently skip school the client states he smokes half a pack of cigarettes per day a client gave his favorite possessions to his friends***
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A nurse in an emergency mental health facility is caring for a group of clients the nurse should identify that which of the following clients requires a temporary emergency admission
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A client who has schizophrenia with delusions of grandeur A client who has manifestations of depression and attempted suicide a year ago a client who has borderline personality disorder and assaulted a homeless man with a metal rod *** a client who has bipolar disorder and paces quickly around the room while talking to himself
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A nurse decides to put a client who has psychotic disorder in a secluded room overnight because the unit is very short staffed and the client frequently fights with other clients. the nurses actions are in example of which of the following torts
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Invasion of privacy false imprisonment *** assault battery
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A client tells a nurse don't tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate who is always yelling at me and threatening me. which of the following actions should the nurse take
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Keep the clients communication confidential but talk to the client daily use therapeutic communication to convince him to admit to hiding the knife keep the clients communication confidential but watch the client and his roommate closely tell the client that this must be reported to the healthcare team because it concerns the health and safety of the client and others *** report the incident to the healthcare team but do not inform the client of the intention to do so
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A nurse is caring for a client who is in mechanical restraints. which of the following statements should the nurse include in the documentation (Select All the apply)
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client ate most of his breakfast client was offered 8 ounces of water every hour *** client shouted obscenities at assistive personnel *** client received chlorpromazine 15 mg by mouth at 1000 *** client acted out after lunch
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A nurse here's a newly licensed nurse discussing a clients hallucinations in the hallway with another nurse which of the following actions should the nurse take first
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Notify the nurse manager Tell the nurse to stop discussing the behavior*** provide an in-service program about confidentiality complete an incident report
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A nurse observes a client who has OCD repeatedly applying removing and then reapplying make up. the nurse knows that the repetitive behavior in a client who has OCD is due to which of the following underlying reasons
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Narcissistic behavior fear of rejection from staff attempt to reduce anxiety *** adverse affect of antidepressant medication
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A nurse is caring for a client who is experiencing a panic attack which of the following actions should the nurse take
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Discuss new relaxation techniques show the client how to change his behavior distract the client with a television show stay with the client and remain quiet***
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A nurse is assessing a client who has generalized anxiety disorder. which of the following findings should the nurse expect (select all that apply).
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Excessive worry for six months *** impulsive decision making delayed reflexes restlessness *** need for reassurance***
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A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first
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Assessing the clients risk for self harm *** instilling hope for a positive outcomes encouraging the client to participate in group therapy sessions encouraging the client to participate in treatment decisions
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A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety which of the following statement actions should the nurse make
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Tell me about how you were feeling right now *** you should focus on the positive things in life to decrease your anxiety why do you believe you are experiencing this anxiety Lets discuss the medication is your provider is prescribing to decrease your anxiety
