ATI Mental Health Practice Part B with NGN

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? - Easily distracted Extreme distractibility is a hallmark manifestation of delirium. A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? - "I'll stay with you just in case you want to talk." This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings. A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? - A 35- year-old client who has major depressive disorder. A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - "I will update the plan of care as a client's manifestations of depression change." The nurse should update the plan of care as a client's status and needs change. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? - Blood pressure 154/96 mm Hg Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever. A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? - Nonmaleficence It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit. A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? - The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program. A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? - Renew the prescription for the client every 4 hr. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? - Inform the client that this admission is confidential. According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship. A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdiscplinary services for the client at home? - Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy. A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? - Spending adequate time with a client who is verbally abusive By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care. A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? - "It is important for our child to have regular dental checkups." For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa. A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? - Greater risk of attempting suicide as affect and energy improve The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment. A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? - Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? - Identify the client's trigger foods. The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food. A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make? - "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures. A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? - Acute dystonia The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? - Tooth erosion A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting. A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? - Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - 1.5 mL A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? - A client who is experiencing delusions of persecution The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? - Language delay The nurse should identify that language delays are a manifestation of autism spectrum disorder. A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? - 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 to prevent further injury to themselves or others. A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? - An older adult client who is bedbound and has a stage IV pressure ulcer A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting. A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching? - "I will not take charge of my partner's work responsibilities." The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.