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MENTAL HEALTH ATI - ASSESSMENT A
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MENTAL HEALTH ATI - ASSESSMENT A
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MENTAL HEALTH ATI - ASSESSMENT AAdnursedindmentaldhealthdfacilitydobservesdadclientdwhodisdexperiencingdpanicdleveldofdanxi
ety.dWhichdofdthedfollowingdactionsdshoulddthednursedtakedfirst?d-dans--
Accompanydthedclientdtodadquietdroom.d(Greatestdriskdfordthisdclientdisdinjurydduedtodsevere
danxiety.dTherefore,dfirstdactiondnursedshoulddtakedisdtodstaydwithdclientdanddbringdhimdtoda
droomdwithdminimaldstimuli.)
Adnursedisdobtainingdadhistorydanddphysicaldondadclientdwhodpresentsdtodthedemergencydd
epartmentdofdadmentaldhealthdfacility.dThednursedrecognizesdwhichdofdthedfollowingdasses
smentdfindingsdasdbeingdconsistentdwithdPTSD?d(Selectdalldthatdapply)d-dans--
Distressingddreams
Difficultydconcentrating
Exaggerateddstartledresponse
Adnursedisdprovidingdteachingdtodadclientdwhodhasdadnewdprescriptiondfordhaloperidol.dWhi
chdofdthedfollowingdsidedeffectsdshoulddthednursedinstructdthedclientdtodreportdtodthedprovid
er?d-dans--
Shufflingdgait.d(Clinicaldfindingsdofdpseudoparkinsonismdsuchdasdshufflingdgaitdmaydoccurd
5hrd-
d30ddaysdafterdbeginningdtreatment.dThedclientdshoulddnotifydthedproviderdwhodmightdpres
cribedandantidparkinsonismdagent.)
Adhomedhealthdnursedisdassessingdandolderdadultdclientdwhodlivesdalone.dWhichdofdthedfoll
owingdfindingsdshoulddindicatedtodthednursedthatdthedclientdisdexperiencingddelirium?d-
dans--Suddendonset.d(Clientsdusuallyddevelopddeliriumdsuddenlydoverdhoursdtoddays.)
Adnursedisdcaringdfordadclientdreceivingdimipraminedforddepression.dFordwhichdofdthedfollow
ingdadversedeffectsdshoulddthednursedmonitor?d-dans--Urinarydretention.
Adnursedisdprovidingdcaredfordadclientdwhodhasdbipolarddisorderdanddisdexperiencingdacuted
mania.dClient'sdmorningdlithiumdleveldisd1.5dmEq/
L.dWhichdofdthedfollowingdadditionaldlaboratoryddatadhasdthedhighestdpriority?
a)dSerumderythrocytedsedimentationdrated18dmm/hr
b)dHemoglobind15dg/dL
c)dserumdT4d5dmcg/dL
d)dSerumdsodiumd125dmEq/Ld-dans--
Serumdsodiumd125dmEq/
Ld(Indthedpresencedofdlowdsodiumdlevels,drenaldexcretiondofdlithiumdisdreduceddanddclientdi
sdatdriskdfordlithiumdtoxicity.dTherefore,dthisdfindingdisdhighestdprioritydbecauseditdplacesdcli
entdatdgreatestdriskdfordinjury.)
, Adnursedisdcaringdfordadclientdwhodhasdadhistorydofdsubstancedusedanddwasdinvoluntarilyda
dmitteddtodadmentaldhealthdfacility.dWhendthednursedattemptsdtodadministerdoraldlorazepa
m,dthedclientdrefusesdtodtakedthedmedicationdanddbecomesdphysicallydaggressive.dWhichd
ofdthedfollowingdactionsdshoulddthednursedtake?d-dans--
Dodnotdadministerdthedlorazepam.d(Clientsdwhodaredinvoluntarilydadmitteddretaindthedrightd
todrefusedtreatment.)
Adnursedisddevelopingdaddischargedplandfordadclientdwhodhasdadhistorydofdgamblingddepen
dencydanddincludesdparticipationdindsupportdgroup.dThednursedshoulddtelldthedclientdthatdw
hichdofdthedfollowingdisdthedpurposedofdattendingdadsupportdgroup?d-dans--
Providedassurancedthatdothersdhavedadsimilardproblem.d(Participatingdindadsupportdgroupd
withdotherdindividualsdwhodhavedsimilardproblemsdwilldshowdthedclientdthatdhedisdnotdthedo
nlydonedwithdthisdproblem.dThedclientdcandlearndalternativedwaysdtodsolvedproblemsdthatdot
herdmembersdofdthedgroupdhavedalsodexperienced.)
Adnursedisdcaringdfordadclientdwhodisddeafdanddisdscheduleddtodhavedelectroconvulsivedther
apyd(ECT).dProviderdneedsdtodexplaindproceduredtodclientdindorderdtodobtaindinformeddcon
sent.dWhichdofdthedfollowingdactionsdshoulddthednursedtake?d-dans--
Requestdadprofessionaldinterpreterdtodtranslate.
Nursedisdplanningdadteachingdsessiondregardingdthedcodedofdethicsdfordregistereddnurses.d
Whichdofdthedfollowingdshoulddthednursedincludedindthedeaching?d-dans--
Rightdtodtreatmentdensuresdindividualizeddcare.
Nursedisdcaringdfordfourdclientsdindandinpatientdmentaldhealthdfacility.dWhichdofdthedfollowin
gdclientsdcandgivedinformeddconsent?d-dans--Ad35-year-
olddwhodhasdmajorddepressiveddisorder.
Adnursedisdcaringdfordclientdwhosedchilddrecentlyddieddindadmotordvehicledcrashdanddstates,
d"Idjustdwantdtodjoindhim."dWhichdofdthedfollowingdisdthednurse'sdprioritydresponse?d-
dans--"Aredyoudthinkingdaboutdharmingdyourself?"d(Greatestdriskdisdself-
injury;dprioritydisdthereforedtodaskdclientdifdshedhasdplansdfordself-harm)
AdnursedisdassessingdadclientdindthedED.dClientdappearsdagitated,dhisdblooddpressuredisd15
2/94dmmdHg,dhisdHRdisd104/
min,danddhisdpupilsdareddilated.dThednursedshoulddsuspectdintoxicationdwithdwhichdofdthedf
ollowingdsubstances?d-dans--
Cocaned(cocainedintoxicationdcausesdtachycardia,delevateddBP,ddilateddpupils,danddagitat
ion.dThesedphysiologicaldfindingsdsuggestdcocainedintoxication).
Adnursedisdcaringdfordadclientdwhodhasdschizophreniadanddisdprescribeddrisperidone.dWhic
hdofdthedfollowingdlaboratorydtestsdshoulddthednursedmonitor?d-dans--
Blooddglucosed(risperidonedcandcauseddiabetesdmellitusdtoddevelop;dtherefore,dnursedsho
ulddplandtodmonitordclient'sdblooddglucosedleveldwhendtakingdthisdmedication)
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