VATI PN MENTAL HEALTH ASSESSMENT GUIDE
NEWEST COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+.
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? CORRECT ANSWER Offer
frequent high-calorie fluids throughout the day.
RAT;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? CORRECT
ANSWER Abdominal pain
RATIONALES ;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? CORRECT ANSWER Explain confidentiality
guidelines to the client.
RATIONALES ;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 actions should the nurse
take? CORRECT ANSWER Move the client to a private examination
room to perform the interview.
RATIONALES ;The nurse should interview the client in a private room
without others present. Providing privacy in a safe environment will
foster trust and promote open communication between the client and
the nurse.
A nurse is caring for a client who is experiencing a severe panic attack.
Which of the following actions should the nurse take during the panic
attack? (Select all that apply.) CORRECT ANSWER 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.
RATIONALES ;Instruct the client to take slow, deep breaths is correct.
The nurse should instruct the client to breathe slowly and deeply to
distract from the distressing manifestations of the attack and reduce the
risk for hyperventilation.
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 from a 5-year-old child who is brought to the
emergency department by a parent who states that the child fell out of
a tree. The child is guarding their right arm. For which of the following
findings should the nurse suspect physical maltreatment? CORRECT
ANSWER An x-ray of the right arm indicates a spiral fracture.
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? CORRECT 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
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