Exam (elaborations) ATI_Mental_Health_Practice_Exam_A.

A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the patient’s ability to cope with this situation? - "To whom do you talk when you feel overwhelmed?" - By asking this question, the nurse is assessing the client’s support system, which is an important factor in the client’s ability to cope with the situation. A nurse is caring for a patient 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 indicates the nurse’s interest in the client and a desire to understand the client’s feelings. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hours 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? - BP 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 fever. A nurse is teaching a family member and a client who has a sew diagnosis of Alzheimer’s disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? - "Take this medication in the evening at bedtime." - The client should take this medication in the evening for optimal effectiveness. - A client should never double the dose after a missed dose due to adverse effects of the medication but should notify the provider. Chewing, crushing, or splitting the medication can affect the absorption of the medication. If the client has difficulty swallowing, the provider can prescribe orally disintegrating tablets. A nurse is discussing a 12-step program with a patient 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. - This is because the client-sponsor relationship has been shown to increase program attendance and the chances of recovery. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? - Assess the client for evidence of a perceptual disturbance. - The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions). A nurse is admitting a patient with major depression disorder and a new prescription for tranylcypromine. Which of the following OTC medications that the patient reports taking should alert the nurse to a potential adverse reaction? - Phenylephrine - Tranylcypromine is an MAOI antidepressant, which should not be taken with phenylephrine and other OTC medications for sinus congestions, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension. A nurse is assessing a patient with schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? - Anhedonia - Negative symptoms of schizophrenia affect a person’s ability to interact with others and are less dominant than the positive symptoms. These symptoms develop over time. Examples are flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking. A nurse emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? - "She won't let me take the trash from her room. I'm concerned about what she has in there." - The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother’s statement indicates awareness of her daughter’s behavior. 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.