Mental Health ATI A with NGN 100% Pass

Mental Health ATI A with NGN 100% Pass A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? ✔✔Encourage freq ...

Mental Health ATI A with NGN 100% Pass A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? ✔✔Encourage frequent rest periods throughout the day A nurse is delegating client care tasks to a LPN and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? ✔✔Change the dressings of a client who has borderline personality disorder and superficial self-inflected wounds A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10mg/5mL. How many mL should the nurse administer? ✔✔14 mL A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicated that the client is using denial as a defense mechanism? ✔✔"I am able to go to work everyday, so I don't have a problem." A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? ✔✔Substance abuse disorder A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse questions the client's speech pattern as which of the following? ✔✔Clang association A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? ✔✔St. Johns Wort A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? ✔✔"In the event a client threatens to harm others, medication can be administered without consent." A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? ✔✔Anhedonia A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? ✔✔Encourage the client to drink 125 mL of fluid each hour while awake. A nurse is caring for a group of clients. Which of the following findings should the nurse report? ✔✔A client who is taking lamotrigine and has developed a rash. A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? ✔✔Instruct the client to avoid driving during initial therapy A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? ✔✔Arrange one-to-one observation of the client. A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? ✔✔Inappropriate dress A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? ✔✔A client who has borderline personality disorder threatened to harm their roommate A nurse is caring for a group of clients. For which of the following situations should the nurse complete the incident report? ✔✔A client was administered one-half of the prescribed dose of medication. A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? ✔✔Do not administer the lorazepam A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? ✔✔A client who has a sodium level of 128 mEq/L A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? ✔✔Frequently misplaces objects A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential or contraindicated for the client. ✔✔Decrease sensory stimulation: anticipated Give directions to the client slowly and in moderate tone of voice: anticipated Ensure the bed is kept at a working height for the nurse: contraindicated Provide the client with a high-calorie protein drinks hourly: nonessential Use a vest restrain to keep the client in a medical recliner: contraindicated Keep the lights off in the clients bedroom and bathroom at night: contraindicated Assign the client to a room near the nurses station: anticipated When addressing the client, approach them from the front when possible: anticipated A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? ✔✔Talk with the client about activities they enjoyed with their partner. A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? ✔✔Respite care During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? ✔✔The client is interested in what the nurse is saying. A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? ✔✔Promote the use of music to compete with the client's auditory hallucinations. A nurse is caring for a client who is undergoing electroconvulsive therapy and will receive succinycholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? ✔✔"Succinylcholine is given to reduce muscle movements during therapy." A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? ✔✔Orthostatic hypotension A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? ✔✔Refrains from manipulating others to earn dining room privileges. The client is at greatest risk for _________ as evidence by _____. ✔✔Violent behavior Agitation A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? ✔✔"It is not uncommon to feel angry toward yourself or others." A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? ✔✔Avoid looking directly at the light during treatment. A nurse assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? ✔✔Emotional liability A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? ✔✔Aggression towards animals A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following? ✔✔provide frequent high-calorie snacks The client is at greatest risk for _________ as evidence by _____. ✔✔Hypertensive crisis Consuming foods high in tyramine A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? ✔✔"If you do my homework for me, I won't bother you for the rest of the day." A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? ✔✔"I should eat a regular diet with normal amounts of salt and fluids." A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? SATA ✔✔-Feelings of hopelessness -Anhedonia -Flat facial expressions A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? ✔✔"It is easier to talk about my feelings now." The nurse is assessing a client. Select 5 findings that require a follow up. ✔✔-Nausea and vomiting -Temperature -LOC -BAC -Respiratory rate For each of the clients assessment findings click to specify if the finding is consistent with alcohol toxicity or major depressive disorder. ✔✔Mental status: both LOC: alcohol toxicity Respiratory rate: Alcohol toxicity Weight change: major depressive disorder N/V: alcohol toxicity The client is at greatest risk for developing _________ as evidence by _____. ✔✔Alcohol withdrawal syndrome mental status For each of the potential prescriptions, click to specify if the potential prescription is anticipated, contraindicated or nonessential. ✔✔Obtain CT scan of brain: nonessential Administer an anti-anxiety medication: anticipated Obtain an alcohol use disorders identification test: nonessential Initiate IV access: anticipated Monitor Vs Q30: anticipated Wake the client every 30 min for neurological assessment: contraindicated The nurse should first ______ followed by ______ ✔✔Initiate suicide precautions Initiate IV access The nurse is evaluating the client after interventions for alcohol withdrawal syndrome have been implemented. Which of the following findings indicate a positive response to therapy? ✔✔-Slept 8 hours -Blood pressure -Temperature -Heart rate -Tremors -Respiratory rate A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? ✔✔Set realistic limits on the client's behavior A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? ✔✔Remove unnecessary equipment from the child's surroundings. A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? ✔✔Hand tremors A nurse in a providers office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? ✔✔Dark urine Click to highlight the information in the clients medical record that indicate the clients condition is deteriorating. ✔✔-QT prolongation -Exercise regimen -Hematemesis -BMI A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take? ✔✔Ask the client what the voices are saying A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? ✔✔The client will refrain from selfmutilation. A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? ✔✔Interview the client in a private setting A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? ✔✔"You might experience difficulties with sexual functioning while taking this medication. For each potential assessment finding, click to specify if it is a positive or negative symptom of schizophrenia. ✔✔Absence of intonation in speech: - Alogia: - Delusions of grandeur: + Clang associations: + Catatonia: + Withdrawal from social activities: - A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? ✔✔Report the occurrence to the charge nurse A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? ✔✔Attention to body language A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? ✔✔Ask the family member if they have any thoughts or questions about the treatment plan. A nurse is reviewing the electronic medical record of a client who has scizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? ✔✔The client reports an inability to breathe easily. A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? ✔✔The client reports command hallucinations A client who has a diagnosis of depression is attending a group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? ✔✔Allow the client time to formulate an answer