VATI PN Mental Health Assessment, QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+||NEWEST
VERSION
A nurse is assisting with the care of a client immediately
following electroconvulsive therapy (ECT). Which of the
following findings should the nurse document as an
unexpected response to the procedure? -
✔✔ANSWER✔✔-Irregular heart rhythm
An irregular heart rhythm is an unexpected response to
ECT. During the procedure, the client's heart can be
stressed, which can cause cardiac abnormalities.
especially if the client already has impaired cardiac
function. The nurse should document this finding and
notify the charge nurse or the client's provider.
A nurse is caring for a client who is admitted for alcohol
use disorder. The client states, "I have not had anything to
drink for 24 hours." Which the following is the priority
nursing intervention? - ✔✔ANSWER✔✔-Check the client's
vital signs.
,Clients who have alcohol use disorder are at risk for the
development of abstinence syndrome. Manifestations of
abstinence syndrome occur 12 to 72 hr after the client has
last consumed alcohol and can include tachycardia,
hypertension, and an elevated temperature. Therefore, the
first action the nurse should take when using the airway,
breathing, 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 teaching with the adult child of a
client who is scheduled to have electroconvulsive therapy
(ECT). Which of the following statements should the nurse
make? - ✔✔ANSWER✔✔-"Your father might experience
short-term memory loss after the procedure."
The nurse should reinforce to the client's child that short-
term memory loss is a common adverse effect of ECT.
A nurse is assisting with planning care for a client who is
in the manic phase of bipolar disorder. Which of the
following actions is the priority for the nurse to include in
the plan? - ✔✔ANSWER✔✔-Offer frequent high-calorie
fluids throughout the day.
The priority action the nurse should take when using
Maslow's hierarchy of needs is to meet the client's
physiological need for food and fluids. The priority nursing
action is to frequently.offer the client high-calorie fluids to
, prevent dehydration and ensure the client's caloric is
adequate to meet intake physical needs.
A nurse is reinforcing teaching with a client who has
bipolar disorder and a new prescription for valproic acid.
Which of the following manifestations should the nurse
instruct the client to report to the provider as an adverse
effect of this medication? - ✔✔ANSWER✔✔-Abdominal
pain
The nurse should instruct the client that abdominal pain
can indicate hepatoxicity or pancreatitis, both adverse
effects of valproic acid; therefore, the client should report
this to the provider.
A nurse is establishing a therapeutic relationship with a
client who has generalized anxiety disorder. Which of the
following actions should the nurse take first? -
✔✔ANSWER✔✔-Explain confidentiality guidelines to the
client.
Evidence-based practice indicates that the nurse should
first begin a therapeutic relationship with the orientation
phase. During this phase, the nurse should explain the
guidelines for confidentiality. This initial step in developing
a therapeutic relationship builds trust between the client
and the nurse.
A nurse is interviewing an adolescent client who reports
that they were sexually assaulted. Which of the following
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