2023 ATI MENTAL HEALTH REMEDIATION Exam Answered 100% correct

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Eating disorders: planning care for a client who has anorexia nervosa RM MH RN 10.0 Ch 19 - ANSWER -establish realistic goals for weight loss or gain -monitor the client's vital signs, intake and ou ... tput, and weight (2-3 lb/wk is medically acceptable) -reward pt for positive outcomes, such as completing meal or consuming certain amount of calories -closely monitor client during and after meals to watch for purging Legal and ethical issues: identifying ethical principles RM MH RN 10.0 Ch 2 - ANSWER -beneficence: the quality of doing good; can be described as a charity -autonomy: the clients right to make her own decisions. The client must accept the consequences of those decisions. the client must also respect the decisions of others -justice: Fair and equal treatment to all -fidelity: loyalty and faithfulness to the client and to one's on duty -veracity: honesty when dealing with clients Suicide: community referrals RM MH RN 10.0 Ch 30 - ANSWER -females are more than males to attempt suicide -nurses who work with clients who have SI can benefit personally by debriefinng, sharing, and collaborating with other health professionals -nurses can give patients referals to support groups in the community following discharge Mental health issues of children and adolescents: priority intervention for a child who has ADHD RM MH RN 10.0 Ch 28 - ANSWER -safety is always #1 priority; move excessive objects away from childs surrounding to avoid them using these objects to hurt themselves or others -children with ADHD have a decreased perception of their ability to be hurt -children with ADHD have characteristics including *inattention* (difficulty in paying attention, listening, and focusing), *hyperactivity* (fidgeting, inability to sit still, running and climbing inappropriately, difficulty playing quietly, and talking excessively), and *impulsivity* (difficulty waiting for turns, constant interruption, and acting without considering others) -characteristics must be presetn before age 12 Legal and ethical issues: interventions for a child who is in seclusion RM MH RN 10.0 Ch 2 - ANSWER -time limit for restraints are based on age: (>18 y.o. = 4 hrs), (9-17 y.o. = 2 hr), (<8 y.o. = 1 hr) -if need to keep child in restraint longer, the physician must assess the situation and write a new prescription evry 24 hours -use restraints after all other less restrictive means are taken -document on situation every 15-30 minutes -offer patient toileting every 15-30 mins or based on hospital policy -the nurse can use restraints without a prescription if it is an emergency situation; however, after a specific period (usually 15-30 mins) the nurse must obtain a prescription Family and community violence: Identifying secondary prevention strategies RM MH RN 10.0 Ch 32 - ANSWER -screening for patients who are at risk for domestic violence is secondary prevention -early prevention is key! -examples of early prevention: provide psych first aid, make sure clients are physcially and psychologically safe from harm, reduce stress-related manifestations, provide interventions to restore rest and sleep -nurses are mandatory reporters for abuse Mental health issues of children and adolescents: Conduct disorder RM MH RN 10.0 Ch 28 - ANSWER -clients with this disorder demonstrate persistent pattern of behavior that violates the rights of others or rules and norms of society -examples include: aggression towards ppl and animals, destruction of property, deceitfulness or theft, and serious violations of rules -patient demonstrates a lack of remorse or care for the feelings of others -pt exhibits low self-esteem, irritability, outbursts -use a calm, firm approach when talking to patient -set clear limits on unacceptable behavior and be consistent -provide a safe environment for child and others Psychoanalysis, Psychotherapy, and behavioral therapies: operant conditioning RM MH RN 10.0 Ch 7 - ANSWER -the client recieves positive rewards for positive behavior -example: a client receives tokens for good behavior, and he can exchange them for a privilege or other items -does not associate a maladaptive behavior with a punishment - this is aversion therapy! Psychotic disorders: Responding to client report of danger RM MH RN 10.0 Ch 15 - ANSWER -ask client directly about hallucinations; the nurse should not argue with or agree with the patients hallucinations, but offer comment on them -do not argue with the clients delusions, but focus on the clients feelings and possibly offer reasonably explanations -assess the client for paranoid delusions, which can increase risk of violence against others -if client is experiencing command hallucinations, provide for safety due to increased risk of harm to self or others -identify symptom triggers Group and family therapy: boundaries RM MH RN 10.0 Ch 8 - ANSWER -boundaries are distinguishable between family roles -clear boundaries define roles of each member and are understood by all -enmeshed boundaries: thoughts, roles, and feelings blend so much that individual roles are unclear (ex: older siblings caring for younger siblings) -rigid boundaries: rules and roles are completely inflexible. these families tend to have members that isolate themselves Bipolar disorders: Planing care for a client who is experiencing mania RM MH RN 10.0 Ch 14 - ANSWER -expected findings during mania: labile mood with euphoria, agitation, irritability, restlessness, grandiosity, increase in talking and activity, impulsiveness -main focuses is on safety and maintaining physical health -create therapeutic milieu, provide a safe environment -decrease stimulation without isolating the patient as much as possible -implement frequent rest periods (napping is okay) -provide outlets for physical activity -protect client from poor judgement and impulsie behaviors Group and Family Therapy: facilitating a community meeting RM MH RN 10.0 Ch 8 - ANSWER -group therapy goals: sharing common feelings and concerns, sharing stories and experiences, diminishing feelings of isolation, creating a community of healing and restoration -phases of meeting: orientation phase, working phase, termination phase -use open and clear communication -cohesiveness and guidelines for a therapy session -opportunities for development of interpersonal skills; resolution of personal and family issues; and development of appropriate, satisfying relationships Anxiety disorders: teaching a client about relaxation techniques RM MH RN 10.0 Ch 11 - ANSWER -relaxation training is used to control pain, tension, and anxiety -modeling is a relaxation technique: allows client to see a demonstration of appropriate behavior in a stressful situation; the goal of this is that pt will imitate behavior -flooding: involves exposing the client to a great deal of an undesireable stimulus in an attempt to turn off the anxiety response -educate client regarding identification of manifestations of anxiety creating and maintaining a therapeutic and safe environment: room assignment RM MH RN 10.0 Ch 5 - ANSWER -depressed patients should not be put alone and feel isolated if you can help it -consideration the personalities of each roommate when considering room assignment -consider the likelihood of nighttime disruptions for a roommate if one client has difficulty sleeping -consider mental health and medical Dx when assigning roommates Medications for bipolar disorders: Lithium toxicity RM MH RN 10.0 Ch 23 - ANSWER -early indications of toxicity: (<1.5mEq/L), diarrhea, nasuea, vomiting, thirst, muscle weakness, fine hand tremor, slurred speech; instruct client to withhold meds -advanced indications: (1.5-20 mEq/L), mental confusion, sedation, poor coordination, coarse tremors, and ongoing GI distress; withhold meds, notify provider, excretion can be promoted if needed -severe toxicity (2.0-2.5 mEq/L), extreme polyuria, dilute urine, tinnitus, giddiness, jerking movemetns, blurred vision, ataxia, severe hypoTN, stupor, possible death from resp depression; administer an emetic if pt is alert, or gastric lavage; urea, mannitol, or aminophylline can increase rate of excretion -greater than 2.5 mEq/L: rapid progression of manifestations leading to death; hemodyalisis can be initiated -lithium is very hard on kidneys, watch their functioning Suicide: evaluating treatment effectiveness RM MH RN 10.0 Ch 30 - ANSWER -suicidal comments are usually made to someone the patient believes is supportive; they can be overt or covert -when patients say they have more energy, they are at a higher risk of suicide -patients usually express kindness to love ones prior to completing suicide -patients that can express their feelings indicate effective treatment A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? - ANSWER 1. Occupational therapy 2. Meal delivery services 3. Home health services 4. Physical therapy A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? - ANSWER Wear sunglasses when outdoors -light therapy, or phototherapy, can cause eye strain and sensitivity to light A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? - ANSWER Call for a team of staff members to help with the situation -the greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance and to prevent further injury to himself or others [Show More]

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