PN VATI MENTAL HEALTH 2024 ACTUAL EXAM
TEST BANK QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
Terms in this set (50)
A nurse is assisting with Irregular heart rhythm
the care of a client
immediately following An irregular heart rhythm is an unexpected response
electroconvulsive therapy to ECT. During the procedure, the client's heart can
(ECT). Which of the be stressed, which can cause cardiac abnormalities.
following findings should especially if the client already has impaired cardiac
the nurse document as an function. The nurse should document this finding and
unexpected response to notify the charge nurse or the client's provider.
the procedure?
Check the client's vital signs.
A nurse is caring for a Clients who have alcohol use disorder are at risk for
client who is admitted for the development of abstinence syndrome.
alcohol use disorder. The Manifestations of abstinence syndrome occur 12 to 72
client states, "I have not hr after the client has last consumed alcohol and can
had anything to drink for include tachycardia, hypertension, and an elevated
24 hours." Which the temperature. Therefore, the first action the nurse
following is the priority should take when using the airway, breathing,
nursing intervention? circulation (ABC) approach to client care is to check
the client's vital signs to monitor for signs of
abstinence syndrome.
,A nurse is reinforcing "Your father might experience short-term memory
teaching with the adult loss after the procedure."
child of a client who is
scheduled to have The nurse should reinforce to the client's child that
electroconvulsive therapy short-term memory loss is a common adverse effect
(ECT). Which of the of ECT.
following statements
should the nurse make?
Offer frequent high-calorie fluids throughout the day.
A nurse is assisting with
planning care for a client The priority action the nurse should take when using
who is in the manic phase Maslow's hierarchy of needs is to meet the client's
of bipolar disorder. Which physiological need for food and fluids. The priority
of the following actions is nursing action is to frequently.offer the client high-
the priority for the nurse calorie fluids to prevent dehydration and ensure the
to include in the plan? client's caloric is adequate to meet intake physical
needs.
A nurse is reinforcing Abdominal pain
teaching with a client who
has bipolar disorder and a The nurse should instruct the client that abdominal
new prescription for pain can indicate hepatoxicity or pancreatitis, both
valproic acid. Which of the adverse effects of valproic acid; therefore, the client
following manifestations should report this to the provider.
should the nurse instruct
the client to report to the
provider as an adverse
effect of this medication?
Explain confidentiality guidelines to the client.
A nurse is establishing a
therapeutic relationship
Evidence-based practice indicates that the nurse
with a client who has
should first begin a therapeutic relationship with the
generalized anxiety
orientation phase. During this phase, the nurse should
disorder. Which of the
explain the guidelines for confidentiality. This initial
following actions should
step in developing a therapeutic relationship builds
the nurse take first?
trust between the client and the nurse.
, Move the client to a private examination room to
A nurse is interviewing an
perform the interview.
adolescent client who
reports that they were
The nurse should interview the client in a private room
sexually assaulted. Which
without others present. Providing privacy in a safe
of the following actions
environment will foster trust and promote open
should the nurse take?
communication between the client and the nurse.
Stay with the client is correct. The nurse should stay
with the client during the panic attack to ensure that
the client remains safe and reduce feelings of
abandonment.
A nurse is caring for a
client who is experiencing
Instruct the client to take slow, deep breaths is
a severe panic attack.
correct. The nurse should instruct the client to breathe
Which of the following
slowly and deeply to distract from the distressing
actions should the nurse
manifestations of the attack and reduce the risk for
take during the panic
hyperventilation.
attack? (Select all that
apply.)
Set physical limits is correct. The nurse should set
physical limits to maintain the safety of the client and
others because the client might have difficulty
controlling their actions during the attack.
A nurse is collecting data An x-ray of the right arm indicates a spiral fracture.
from a 5-year-old child
who is brought to the The nurse should identify that an x-ray indicating a
emergency department by fracture can be an expected finding for a child who
a parent who states that fell out of a tree. However, a spiral fracture is caused
the child fell out of a tree. by twisting of the extremity and can be an indication
The child is guarding their of physical maltreatment. The nurse should report the
right arm. For which of the findings to the registered nurse.
following findings should
the nurse suspect physical
maltreatment?
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