ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+, Exams of Nursing

Download ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ and more Exams Nursing in PDF only on Docsity! ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A client, age 36, with paranoid schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development? A) Autonomy versus shame and doubt B) Generativity versus stagnation C) Integrity versus despair D) Trust versus mistrust This client's paranoid ideation indicates difficulty trusting others. The stage of autonomy versus shame and doubt deals with separation, cooperation, and self-control. Generativity versus stagnation is the normal stage for this client's chronologic age. Integrity versus despair is the stage for accepting the positive and negative aspects of one's life, which would be difficult or impossible for this client ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate? A) Helping the client to participate in social interactions B) Establishing a one- on-one relationship with the client C) Establishing alternative forms of communication D) Allowing the client to decide when he wants to participate in verbal communication with the nurse By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate but should take place only after the nurse-client relationship is established. Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? A) Dismantling the showerhead and showing the client that there is nothing in it B) Explaining that other clients are complaining about the client's body odor C) Asking a security officer to assist in giving the client a shower D) Accepting these fears and allowing the client to take a sponge bath ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality (as in option A) wouldn't be effective at this time. Options B and C would violate the client's rights by shaming or embarrassing the client. Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction? A) Hypertension B) Respiratory arrest C) Tourette Syndrome D) Retinal pigmentation Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other options don't occur as a result of exceeding this dose. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated? A) Several minutes ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A) The absence of anticholinergic effects B) A lower incidence of extrapyramidal effects C) Photosensitivity and sedation D) No incidence of neuroleptic malignant syndrome Risperdal has a lower incidence of extrapyramidal effects than the typical antipsychotics. Risperdal does produce anticholinergic effects and neuroleptic malignant syndrome can occur. Photosensitivity isn't an advantage. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ The etiology of schizophrenia is best described by: A) genetics due to a faulty dopamine receptor. B) environmental factors and poor parenting. C) structural and neurobiological factors. D) a combination of biological, psychological, and environmental factors. A reliable genetic marker hasn't been determined for schizophrenia. However, studies of twins and adopted siblings have strongly implicated a genetic predisposition. Since the mid-19th century, excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia. Therefore, a combination of biological, psychological, and environmental factors are thought to cause schizophrenia. A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A) benztropine (Cogentin) B) dantrolene (Dantrium) C) clonazepam (Klonopin) D) diazepam (Valium) Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine drug, is administered to reduce anxiety. A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response? A) Say, "You know it's your medicine." B) Allow him to open the individual wrappers of the medication. C) Say, "Don't worry about what is in the pills. It's what is ordered." D) Ignore the comment because it's probably a joke. Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ have anticholinergic effects, such as urine retention, dry mouth, and constipation. Urinary frequency isn't an approved nursing diagnosis. Although antipsychotic medications may cause sedation, they don't severely decrease the level of consciousness, eliminating option C. These drugs don't cause electrolyte disturbances, eliminating option D. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? A) Dystonia B) Akathisia C) Pseudoparkinsonis m D) Tardive dyskinesia An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that commonly are irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease. An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that commonly are irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease. A) Meeting all of the client's physical needs B) Giving the client an opportunity to express concerns C) Administering lithium carbonate (Lithonate) as prescribed ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ D) Providing a quiet environment where the client can be alone Because a client with catatonic schizophrenia can't meet physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. This client is incapable of expressing concerns; however, the nurse should try to verbalize the message conveyed by the client's nonverbal behavior. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware of the environment, the client doesn't interact with it actively; the nurse's support and presence can be reassuring. A client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client? A) chlorpromazine (Thorazine) B) imipramine (Tofranil) C) lithium carbonate (Lithane) D) fluphenazine decanoate (Prolixin Decanoate) Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it's commonly prescribed for outpatients with a history of medication ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of: A) Paranoid personality disorder B) Avoidant personality disorder C) Histrionic ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ personality disorder D) Borderline personality disorder This client's behaviors are typical of histrionic personality disorder, which is marked by excessive emotionality and attention seeking. The client constantly seeks and demands attention, approval, or praise; may be seductive in behavior, appearance, or conversation; and is uncomfortable except when she is the center of attention. Typically, a client with paranoid personality disorder is suspicious, cold, hostile, and argumentative. Avoidant personality disorder is characterized by anxiety, fear, and social isolation. Borderline personality disorder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships. The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered? A) To reduce psychotic symptoms B) To reduce extrapyramidal symptoms C) To control nausea and vomiting D) To relieve anxiety ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? A) Monthly blood tests will be necessary B) Report a sore throat or fever to the physician immediately. C) Blood pressure must be monitored for hypertension. D) Stop the medication when symptoms subside A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes the phenothiazine thioridazine (Mellaril) 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: A) deeper sleep than CNS depressants. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ concentrate on determining whether the client is hallucinating by assessing thought processes and decision-making ability. Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions? (Choose all that apply) A) Use sunscreen because of photosensitivity B) Take the antipsychotic medication with food C) Have routine blood tests to determine levels of the medication D) Abstain from eating aged cheese Positive symptoms of schizophrenia include which of the following? A) Hallucinations, delusions, and disorganized thinking B) Somatic delusions, echolalia, and a flat affect C) Waxy flexibility, alogia, and apathy D) Flat affect, avolition, and anhedonia The positive symptoms of schizophrenia are distortions of normal functioning. Option A lists the positive symptoms of schizophrenia. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms list the diminution or loss of normal ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ function. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction? A) Dystonia B) Akanesia C) Akathisia D) Tardive dyskinesia A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? A) Word salad B) Tangential C) Perseveratio n D) Avolition Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential is where a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions. An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A) phenytoin (Dilantin) B) amantadine (Symmetrel) C) benztropine (Cogentin) D) diphenhydramine (Benadryl) An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism; diphenhydramine or benztropine may be used to control other extrapyramidal effects. Phenytoin is used to treat seizure activity. Important teaching for a client receiving risperidone (Risperdal) would include advising the client to: A) double the dose if missed to maintain a therapeutic level. B) be sure to take the drug with a meal because it's very irritating to the stomach. C) discontinue the drug if the client reports weight gain. D) notify the physician if the client notices an increase in bruising. notify the physician if the client notices an increase in bruising. Rationale: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. Don't double the dose. This drug doesn't irritate the stomach, and weight gain isn't a problem. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting: A) suggestibility. B) negativity C) Waxy flexibility D) retardation Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement) also occur in catatonic clients. A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger? A) "If it had been your emergency, I would have made the other client wait." B) "I know it's frustrating to wait. I'm sorry this happened." C) "You had to wait. Can we talk about how this is making you feel right now?" ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ D) "I really care about you and I'll never let this happen again." This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option A wouldn't address the client's anger. Option B is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option D, because such matters are outside the nurse's control. A client begins clozapine (Clozaril) therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? A) Hepatitis B) Infection C) Granulocytopenia D) Systemic dermatitis ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Because family members of a client with schizophrenia face difficult situations and great stress, the nurse should inform them of support services that can help them cope with such problems. The nurse should also teach them that medication can't prevent relapses and that environmental stimuli may precipitate symptoms. Although stress can trigger symptoms, the nurse shouldn't make the family feel responsible for relapses (as in option D). A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by: A) loss of identity and self-esteem. B) multiple personalities and decreased self-esteem. C) disturbances in affect, perception, and thought content and form. D) persistent memory impairment and confusion. The Diagnostic and Statistic Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Loss of identity sometimes occurs but is only one characteristic of the disorder. Multiple personalities typify multiple personality disorder, a dissociative personality disorder. Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia doesn't cause a disturbance in sensorium, although the client may exhibit confusion, disorientation, and memory impairment during the ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ acute phase. The nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should: A) ask the client which activity he would prefer to do first B) negotiate a time when the client will perform activities. C) tell the client specifically and concisely what needs to be done. D) prepare the client ahead of time for the activity. The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: A) Delusions B) Hallucinations C) Loose associations D) Neologisms ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client. The nurse is aware that antipsychotic medications may cause which of the following adverse effects? A) Increased production of insulin B) Lower seizure threshold C) Increased coagulation time D) Increased risk of heart failure Antipsychotic medications exert an effect on brain neurotransmitters that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect of antipsychotic agents A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is: A) Highly important or famous B) Being persecuted C) Connected to events unrelated to oneself D) Responsible for the evil in the world ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ "As a nurse, I am required by law to report suspected child abuse." A nurse is assessing an older adult client who lives with her daughter. The older client has several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? Report the findings to a supervisor. A client on a mental health unit refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to prevent him from leaving the hospital. Restraining this client would be considered which type of civil action by the nurse? False imprisonment An adolescent client in an emergency department reports being sexually assaulted just prior to admission. Which of the following actions should the nurse assessing the client take? Ask the client to describe the situation. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nursing instructor is teaching a group of nursing students which factors to include in an abuse assessment of a client. Which of the following factors should not be included in this teaching? Socioeconomic status A nurse in an emergency department is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child? "It is not your fault that this happened." A nursing instructor is teaching a group of nursing students about domestic violence. Which of the following statements by one of the students indicates a need for clarification? "I have heard that abusers think of themselves as important and have high self esteem." A nurse is assessing a client in an emergency department who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication? Be direct and honest when speaking with the client. A nurse suspects that an older client is being neglected by a family caregiver. Which of the following statements by the caregiver should the nurse identify as the priority to address? "We buy the prescriptions we can afford.” ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is assessing a toddler and notices that he has several bruises. Which of the following actions should the nurse take first? Ask the parents what caused the bruises. A nurse in the emergency department is caring for a woman who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident? Close friend A nursing instructor is discussing child abuse with a group of nursing students. Which of the following children should the nursing students identify as a potential victim of abuse? A child whose parents answer questions for the child. A nurse on a mental health unit is assessing a woman who has experienced intimate partner abuse. The nurse should monitor the woman for which of the following findings? Self-esteem disturbance A nurse is setting goals for a client who has terminal lung cancer and is at the end of life. Which of the following are realistic goals? The client will receive medication to minimize episodes of breakthrough pain. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A client in an acute mental health facility becomes angry and suddenly throws a chair in the dayroom. Which of the following interventions should the nurse perform first? Attempt to talk the client down. A female client on an acute mental health unit is upset about lost privileges due to repetitive negative behaviors. Which of the following statements by the nurse demonstrates the effective use of assertive communication? "I understand that you are angry. However, I followed the appropriate protocol." An older man is brought to the emergency department by his family after being found wandering outside. During the nurse's assessment, the client flinches when his abdomen is palpated yet responds to questions only by nodding his head. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? Confusion A nurse is talking with a client in an acute mental health facility who has a new diagnosis of chronic kidney disease. Which of the following statements by the client should the nurse identify as an indication of anticipatory grieving? "I just can't believe that this dialysis is going to ruin my whole life." An adolescent female in an acute mental health facility has attention deficit hyperactivity disorder (ADHD). The nurse should expect which of the following findings? ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Impulsivity A school-age child with ADHD is being discharged from an acute mental health facility. The nurse is teaching the parents about atomoxetine. Which of the following instructions should the nurse include in the teaching? "Give the dose in the morning to help prevent insomnia." A nurse is planning care for a child in an acute mental health facility who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care? Establish a reward system for positive behavior. A nursing instructor is teaching a group of nursing students about autism. The nursing students demonstrate understanding of autism when they state that they would expect to see manifestations of autism in which of the following clients? Toddler ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A client who is suicidal declines the nurse's request to make a safety contract. Which of the following actions should the nurse identify as the priority? Assign a staf f member to stay with the client at all times. A client diagnosed with major depressive disorder tells the nurse, "My family would be better off if I were gone." Which of the following is the nurse's priority response? "Are you thinking of harming yourself?" A nurse in an acute mental health facility is assessing a newly admitted adolescent following a suicide attempt. The nurse should determine that which of the following is the priority risk factor for suicide attempt? Previous suicide attempt A nurse is talking to a client 2 days after being admitted to an acute mental health facility for treatment of depression. The client leaves group, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take? Ask the client if she has a plan to commit suicide. A nurse is admitting a female adolescent following a suicide attempt. The client has a diagnosis of major depressive disorder, anorexia nervosa, and has a history of substance abuse. Which of the following actions is the nurse's priority? ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse in an acute mental health facility is assessing a client who is experiencing a normal grief reaction following the loss of his spouse. Which of the following findings should the nurse expect? Insomnia A nurse is assessing a client who is experiencing grief following the unexpected death of her spouse. Which of the following statements by the client indicates she is experiencing maladaptive grieving "I have started smoking again." A nurse in an acute mental health facility is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grieving? A client who is diagnosed with metastatic lung cancer. A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? Increasing feelings of anger. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is assessing a 30-year-old female in an emergency department. Which of the following statements made by the woman would indicate that she is experiencing a crisis? "I don't understand. I can't seem to function like I usually do." A client's 5-year-old poodle ran in front of a car and was killed. The client continues to be upset by her pet's death, and she explains to a community counseling center nurse that she can't stop crying because, "My Precious meant the world to me, and now my world will never be the same!" Which of the following types of crisis is the client most likely experiencing? Situational Resilience, the capacity to rebound from stressors via adaptive coping, is associated with positive mental health. Your friend has just been laid off from his job. Which of the following responses on your part would most likely contribute to his enhanced resilience? a. using your connections to set up an interview with your employer b. connecting him with a friend of the family who owns his own business c. supporting him in arranging, preparing for, and completing multiple interviews d. helping him to understand that the layoff resulted from troubles in the economy and is not his fault Resilience develops from the process of resolving distress through adaptive coping. It is enhanced when people experience success as a result of their own efforts, increasing their sense of control or mastery over stressful events. Supporting your friend in his efforts to obtain and succeed in interviews for a replacement job contributes to his enhanced resilience. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Which of the following situations best supports the diathesis-stress model of mental illness development? a. the rate of suicide increases during times of national disaster and despair b. a woman feels mildly anxious when asked to speak to a large group c. a man with no prior mental health problems experiences sadness after his divorce d. a man develops schizophrenia, but his identical twin remains free of mental illness The diathesis-stress theory states that some persons are born with a biological predisposition to mental illness but that mental illness does not necessarily develop unless those susceptible persons are exposed to stressors that trigger the illness. Thus, two persons may have the same genetic profile, but one might develop a mental illness due to stressful life experiences whereas the other, despite having the same genetic makeup, has a different life experience and fails to develop the illness. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?: 1. auditory hallucinations 2. delusions of grandeur 3. poor personal hygiene 4. psychomotor agitation A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question: 1. "How long has the voice been directing your behavior?" 2. "Does what the voice tell you to do frighten you?" 3. "Do you recognize the voice speaking to you?' 4. "What is the voice telling you to do?" A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?: 1. powerlessness 2. social isolation 3. risk for suicide 4. compromised family coping A depressed patient says, "Nothing matters anymore." What is the most ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ appropriate response by the nurse?: 1. "Are you having thoughts of suicide?" 2. "I am not sure I understand what you are trying to say." 3. "Try to stay hopeful. Things have a way of working out." 4. "Tell me more about what interested you before you became depressed." A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply: 1. imbalanced nutrition: more than body requirements 2. disturbed thought processes 3. sleep deprivation 4. chronic confusion 5. social isolation ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply: 1. touch the patient to provide reassurance 2. invite the patient to lead a community meeting 3. provide a structured environment for the patient 4. ensure that the patient's nutritional needs are met 5. design activities that require the patient's concentration The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply: 1. channeling excessive energy 2. reducing guilty ruminations 3. instilling a sense of hopefulness 4. assisting with self-care activities 5. accommodating psychomotor retardation Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply: 1. maintain arm's-length, one-on-one direct observation at all times 2. check all items brought by visitors and remove risk ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?: 1. sit with the client and offer simple, direct information 2. have the client attend group therapy immediately 3. explain the unit policies to the client and answer any questions he might have 4. take the client on a tour of the unit and introduce him to all the staff members on duty A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for Buproprion. Which of the following statements by the client indicates understanding of the teaching?: 1. "I may develop a slow heartbeat while taking Bupropion." 2. "I can drink one glass of wine with dinner each day while taking Bupropion." 3. "I may not notice a lifting of my mood for at least 2 weeks." 4. "I should watch for increased salivation and drooling while taking Bupropion." ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation?: 1. "I had a great trip to the Smokey Mountains." 2. "Going back to work has been okay." 3. "I just don't like going to the movies like I used to." 4. "I can't wait to have my family together next weekend." A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm really feeling down and don't want to talk to anyone right now." Which of the following responses should the nurse make?: 1. "It might help you feel better if you talk about it." 2. "I'll just sit here with you for a few minutes then." 3. "I understand. I've felt like that before, too." 4. "Why are you feeling so down?" A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?: 1. "Everyone feels better after showering." 2. "You must be getting better. You look great!" 3. "I see you have done some grooming today." 4. "Why are you all dressed up today? Is it a special occasion?" ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse in an acute mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?: 1. encourage family to take the client out of the facility for short periods of time 2. reward the client for her change in behavior 3. monitor the client's whereabouts at all time 4. ask the client why her behavior has changed A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?: 1. ask the client if she has a plan to commit suicide 2. recognize the attempt at manipulation and escort the client back to her activity 3. assist the client to her room allowing her to rest before resuming activity 4. notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Which of the following findings is this client exhibiting?: 1. flight of ideas 2. grandiosity 3. reality testing 4. Derealization A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?: 1. provide a stimulating environment 2. have consistent unit routines 3. discourage daytime napping 4. schedule daily seclusion times A nurse in an acute mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?: 1. the client has begun playing basketball with several other clients during the past month 2. the client identifies with problems expressed by other clients 3. the client's behavior has become impulsive in the past few weeks ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ 4. the client states that she wants to go home to be with her children and partner A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?: 1. Fluvastatin 2. Carbamazepine 3. Lorazepam 4. Propranol A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ disorder? (Select all that apply). 1. Paroxetine 2. Lithium 3. Donepez il 4. Valproate 5. Carbamazepine A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?: 1."You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." 2."Come with me. Here is a milkshake to drink." 3."We need you to decide what activities you will do today." 4. "You will need to leave the dining room right now and go somewhere else to exercise." The defense mechanisms that can be used in only healthy ways include which of the following? a. Suppression and humour b. Altruism and sublimation ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ c. Fever d. Fear of impending doom Working to help the patient view an occurrence in a more positive light is called which of the following? a. Flooding b. Desensitization c. Response prevention d. Cognitive restructuring Which of the following is the primary purpose of performing a physical examination before beginning treatment for any anxiety disorder? a. Protect the nurse legally b. Establish the nursing diagnosis of priority c. Obtain information about the patient's psychosocial background d. Determine whether the anxiety is primary or secondary in origin ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Which of the following is an important question to ask during the assessment of a patient diagnosed with anxiety disorder? a. "How often do you hear voices?" b. "Have you ever considered suicide?" c. "How long has your memory been bad?" d. "Do your thoughts always seem jumbled?" Which of the following is a possible outcome criterion for a patient diagnosed with anxiety disorder? a. Patient demonstrates effective coping strategies b. Patient reports reduced hallucinations c. Patient reports feelings of tension and fatigue d. Patient demonstrates persistent avoidance behaviours Inability to leave one's home because of avoidance of severe anxiety suggests which of the following anxiety disorders? a. Panic attacks with agoraphobia b. Obsessive-compulsive disorder c Post- traumatic stress response d. Generalized anxiety disorder A teenager changes study habits to earn better grades after initially failing a test. This behavioural change is likely a result of which of the following? ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ a. A rude awakening b. Normal anxiety c. Trait anxiety d. Altruism A young adult applying for a position is mildly tense but eager to begin the interview. This can be assessed as showing which of the following? a. Denial b. Compensatio n c. Normal anxiety d. Selective inattention ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A patient is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the patient reports which of the following? a. That his symptoms started right after he was robbed at gunpoint b. Being so worried he hasn't been able to work for the last 12 months c. That eating in public makes him extremely uncomfortable d. Repeatedly verbalizing his prayers helps him feel relaxed If a patient's record mentions that the patient habitually relies on rationalization, the nurse might expect the patient to do which of the following? a. Make jokes to relieve tension b. Miss appointments c. Justify illogical ideas and feelings d. Behave in ways that are the opposite of his or her feelings Panic attacks in Latin American individuals often involve which of the following? a. Repetitive involuntary actions b. Blushing c. Fear of dying d. Offensive verbalizations The plan of care for a patient who has elaborate washing rituals specifies that ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ response prevention is to be used. Which scenario is an example of response prevention? a. Having the patient repeatedly touch "dirty" objects b. Not allowing the patient to seek reassurance from staff c. Not allowing the patient to wash hands after touching a "dirty" object d. Telling the patient that he or she must relax whenever tension mounts A patient is experiencing a panic attack. The nurse can be most therapeutic by doing which of the following? a. Telling the patient to take slow, deep breaths b. Verbalizing mild disapproval of the anxious behaviour c. Asking the patient what he means when he says "I am dying" d. Offering an explanation about why the symptoms are occurring ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ The nurse caring for a patient experiencing a panic attack anticipates that the psychiatrist would order a stat dose of which of the following? a. Standard antipsychotic medication b. Tricyclic antidepressant medication c. Anticholinergic medication d. A short-acting benzodiazepine medication A military veteran is entering treatment for post-traumatic stress disorder following after a return from duty in Afghanistan. Which of the following is an important facet of assessment? a. Ascertain how long ago the trauma occurred b. Find out if the patient uses acting-out behaviour c. Determine use of chemical substances for anxiety relief d. Establish whether the patient has chronic hypertension related to high anxiety When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should do which of the following? a. Question the physician's order because the dose is excessive b. Explain the long-term nature of benzodiazepine therapy c. Teach the patient to limit caffeine intake d. Tell the patient to expect mild insomnia ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A family where one or both parents witnessed intimate partner violence in the home as children A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first Inform the client that her admission is confidential A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent A 35-year-old client who has major depressive disorder A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following Clang association A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching Language delay ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take Ask the client what the voices are saying A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make "Let's talk about what is upsetting you A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first Discuss the importance of hair with the client A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data Sodium level 125 mEq/l A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD) ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Lack of interest in an upcoming holiday A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take Gather supplies for endotracheal intubation A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first A client who is experiencing delusions of persecution A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation Nonmaleficence ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment Orthostatic hypotension A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider Inability to sleep A charge nurse is developing an educational program about schizophrenia. Which of the following manifestations should the nurse include as a negative symptom of schizophrenia Thought blocking A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching "Administer the last dose of medication to your child 6 hours before bedtime A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take Ask the family member if she has any thoughts or questions about the treatment plan ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism "I am able to go to work every day, so I don't have a problem A nurse in a provider's office is collecting a health history from the parent of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the parent is the priority for the nurse to report to the provider Dark urine A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists in orienting the client to reality Talk with the client about scheduled daily activities A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect Rhinorrhea A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan Identify signs of escalation of violence ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? (Select all that apply Is suicidal, has bipolar, has mania A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take Do not administer the lorazepam A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client The client will refrain from self-mutilation A nurse is teaching coping strategies to a client who is experiencing depression related to intimate partner abuse. Which of the following statements by the client indicates an understanding of the teaching "I will talk about my feelings with a close friend A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ Hypertension During a client's initial interview in a mental health inpatient setting, the nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? The client is interested in what the nurse is saying A charge nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following information should the nurse include in the teaching The right to treatment ensures individualized care A nurse is teaching the parents of a client about their daughter's diagnosis of bulimia nervosa. Which of the following statements made by the parents indicates an understanding of their daughter's illness "It is important for our daughter to have regular dental checkups A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication Urinary retention ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect Increased creatine phosphokinase (CPK) A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching "You may experience difficulties with sexual functioning while taking this medication” A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse An older adult client who is bedbound and has a stage IV pressure ulcer A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate Aggression toward animal A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication The client reports a sore throat A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A.A client wants to know the current time while there is a clock on the wall. B.A client attempts to climb out of bed and repeatedly states she must get ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ home. C. A client requests extra blankets when the thermostat in the room indicates 25.6 Degrees C (78 F). D.A client refuses to get out of bed and has no motivation to attend to daily hygiene. A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? A. Decreased auditory and visual acuity. B. Decreased display of emotion. C. Personality traits that are opposite of original traits. D. Forgetfulness gradually progressing to disorientation. A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.) A. Ability to perform calculations B. Level of consciousness C. Recall ability D. Long-term memory E. Level of orientation ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? A. assist the client to the correct room. B. place the client in restraints. C. re-orient the client to time and place. D. move the client to a room at the end of the hall. A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? A. post a written schedule of daily activities. B. use an overhead loudspeaker to announce events. C. provide a consistent daily routine. D. allow the client to choose free time activities. A nurse is monitoring a client who is post operative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.) A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is caring for a client who is one day post operative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? A. determine the time the client last received pain medication. B. Measure the clients vital signs, including temperature. C. ask the client to rate her pain on a scale of from 0 to 10. D. re-position the client and offer her a back rub. A nurse is planning care for a client who is post operative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.) A. use of analgesics will eventually lead to addiction. B. each clients expression of pain may be different and individualized. C. Patient controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and tolerance can be assessed using a scale from 0 to 10. E. The client will express the feeling of pain both verbally and nonverbally. A nurse is caring for a client your request prescription pain medication. Which of the following actions should the nurse perform first? A. re-position the client. B. administer the medication. C. determine the location of the pain. D. review the effects of the pain medication. ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+ A nurse is applying a cold compress for a client who has pain and minor swelling in a suture laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. inspecting the site for reduced swelling B. monitoring the clients pulse rate C. asking the client to rate the pain D. having the client perform range of motion of the affected arm A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? A. set the pad's temperature to 47.2°C B. stop the treatment if the client's skin becomes red C. leave the pad in place for at least 40 minutes D. use safety pins to keep the pad in place A nurse is caring for a client who is post operative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. vital sign measurement B. The clients self report of pain severity C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure A nurse is caring for a client who requires cold applications with an ice bag to reduce The swelling and pain of an angle injury. Which of the following actions should the nurse take? A. apply the bag for 30 ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE 2021/2022 GRADED A+