VATI Mental Health
A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan? - ANSWER ...
VATI Mental Health
A nurse is planning care for a client following a suicide attempt. Which of the
following interventions should the nurse include in the plan? - ANSWER
Provide the client with plastic eating utensils.
-The client can use glass dishes and metal silverware to cause self harm, therefore,
the nurse should arrange for the client to have only plastic products on their meal
tray.
A nurse is performing an admission assessment for a client who appears withdrawn
and fearful. Which of the following actions should the nurse take first? -
ANSWER
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.
This action establishes trust between the client and the nurse, which in turn
decreases the client's anxiety level.
A nurse is caring for an adolescent client who has anorexia nervosa. The client
states, "Have I done any permanent damage to my body?" Which of the following
,responses should the nurse make? - ANSWER
You're afraid you have caused physical injury to yourself?
-Repeating the main idea of what the client has said, which will allow for
clarification of any misunderstanding on the part of the client or the nurse.
A nurse is caring for a client following a fire that destroyed her home and killed
one of her children. The client is crying and does not make eye contact with the
nurse. Which of the following questions should the nurse ask first? -
ANSWER
Have you thought of harming yourself?
-The greatest risk to this client is self harm due to the loss of her child and home,
therefore, the first question the nurse should ask a client who is having a personal
crisis is to determine if the client has suicidal ideation. If so, the nurse should take
action to protect the client from self harm.
A nurse is checking laboratory values for a hospitalized young adult client who has
bipolar disorder and is taking lithium. Which of the following values is the priority
for the nurse to report to the provider? - ANSWER
Serum creatinine 2.1 mg/dL
-Reference range of 0.5-1.2 mg/dL.
The greatest risk to this client is decreased kidney function, which can cause an
increase in the client's lithium level; therefore, this value is the priority for the
nurse to report to the provider. The clients lithium dosage might need to be
modified based on this lab value. The cause of increased serum creatinine include
dehydration as well as renal disorders. Lithium is contraindicated for clients who
have severe renal disease, cardiac disease, or severe dehydration.
, A nurse is providing information to a client who is seeking voluntary admission to
a mental health facility. Which of the following information should the nurse
include? - ANSWER
You will still need to give informed consent for treatment after admission.
-A client who seeks voluntary admission to a mental health facility has the same
rights as clients receiving any other kind of health care. The client will still need to
give informed consent for treatment and therapies, such as electroconvulsive
therapy.
A nurse is developing a plan of care for an adolescent client who has conduct
disorder. Which of the following interventions should the nurse include in the
plan? - ANSWER
Initiate a behavioral contract with the client.
-A client who has conduct disorder can demonstrate patterns of behavior that are
aggressive, disrespectful of others rights, and can lead to injury of others. A
behavioral contract helps to develop trust between the client and the nurse and
emphasizes the client's responsibility to commit to work on changes in behavior.
A hospice nurse is talking with the family of a client who recently died from
cancer following a series of chemotherapy treatment. One of the adult children is
angry with the provider and blames the provider for their father's death. Which of
the following defense mechanisms is the family member using? - ANSWER
Displacement
-When this family member uses displacement, they are transferring their feelings
of anger to the provider so they do not have to cope with their own feelings of
sadness and loss.
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