ATI Mental Health Assessment B

ATI Mental Health Assessment B 1. A nurse is collecting data from a client who has a history of cocaine use. Which of the following manifestations is an indication that the client is experiencing cocaine toxicity? A) Hypothermia B) Piloerection C) Somnolence D) Seizures: D) Seizures The nurse should expect a client who is experiencing cocaine toxicity to experience seizures. Other manifestations include severe anxiety, hallucinations, and paranoid thoughts. 2. A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? A) "If you can control your actions this week, I'll talk to your parents about extending your curfew." B) "Have you considered participating in a sport to help control your aggres- sion?" C) "If you become aggressive, your parents will take away privileges." D) "You're hurting others. Do you understand why that's wrong?": B) "Have you considered participating in a sport to help control your aggression?" The nurse should encourage the client to participate in sports and other physical activities because they can provide a safer outlet for aggression. 3. A nurse is participating in group therapy for clients who have major depressive disorder. Which of the following topics should the nurse include in the orientation phase of group therapy? A) Confidentiality B) Developing goals C) Problem solving D) Identifying the roles of group members: A) Confidentiality The nurse should establish the expectations of confidentiality during the orientation phase of group therapy. 4. A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The nurse should identify that which of the following findings indicates a potential need for a PRN dose of benztropine? A) Sore throat B) Increased mental confusion C) Urinary retention D) Shuffling gait: D) Shuffling gait The nurse should identify that a shuffling gait can be indicative of the presence of pseudoparkinsonism, which can be treated with a PRN dose of benztropine. 5. A nurse on a mental health unit is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following statements indicates an understanding of the teaching? A) "The consent form should be written at a seventh-grade reading level." B) "If the consent form is signed, I can send a client for a procedure even if she has questions." C) "I should explain everything to the client about the procedure before the client signs the consent form." D) "The consent form should have the name of the provider who is perform- ing the procedure on the form.": D) "The consent form should have the name of the provider who is performing the procedure on the form." The consent form should include the name of the provider who will be performing the procedure. This should be present on the form before the client signs it. 6. A nurse is assisting with the admission of a client to an acute care mental health facility. Which of the following activities should the nurse plan for the working phase of the therapeutic relationship? A) Define the specific responsibilities of the client and of the nurse. B) Assist the client to establish mutual goals. C) Evaluate the client's progress toward meeting his goals. D) Discuss how the client can incorporate new strategies into his daily life.: C) Evaluate the client's progress toward meeting his goals. The nurse should evaluate the progress the client is making toward the goals he has established as part of the working phase of the therapeutic relationship. During the working phase, the nurse and the client identify and implement measures to help the client meet his goals. 7. A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as a predisposing factor for delirium? A) Hepatic failure B) Chronic alcohol use C) Hypertension D) Fluid volume overload: A) Hepatic failure Hepatic failure can be a predisposing factor for the development of delirium. Other potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke. 8. A nurse is caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse report to the charge nurse? A) A client who has schizophrenia is communicating using echolalia B) A client who has depression is exhibiting anergia C) A client who is manic has been pacing the unit for several hours D) A client who has a phobia is using thought stopping: C) A client who is manic has been pacing the unit for several hours The nurse should identify that excessive physical activity in a client who is ex- periencing a manic episode places the client at risk for physical exhaustion and possible death. The nurse should report this client's behavior to the charge nurse. 9. A nurse is reinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make? A) "You should exercise immediately prior to going to sleep." B) "You should listen to music when you feel stress." C) "Take a 1-hour nap every afternoon." D) "You should stop drinking caffeine immediately.": B) "You should listen to music when you feel stress." The nurse should encourage the client to listen to music to increase relaxation. 10. A nurse is caring for a client who is undergoing behavioral therapy for post-traumatic stress disorder (PTSD). The nurse should identify that which of the following findings indicates an improvement in the client's condition? A) The client reports about techniques she uses to promote sleep. B_ The client shows limited emotion when discussing witnessing a traumatic event. C) The client states that she no longer feels like she can trust her partner. D) The client avoids situations that might trigger memories of past trauma.- : A) The client reports about techniques she uses to promote sleep. Clients who have PTSD frequently experience disrupted sleep. Therefore, report- ing about techniques she uses to promote sleep demonstrates that the client's condition has improved. 11. A nurse is caring for a client who has psychiatric somatic symptom disorder. Which of the following actions should the nurse take? A) Obtain the client's vital signs each time the client reports physical illness. B) Remind the client that his symptoms are not real. C) Encourage the client to examine how his illness behavior affects his family. D) Provide adequate time for the client to describe his symptoms.: C) Encour- age the client to examine how his illness behavior affects his family. The nurse should recognize that secondary gains the client might receive are a reprieve from performing duties related to care of the family. The nurse should encourage the client to gain insight into how his illness behavior affects his family, which can help restore family function. 12. A nurse is collecting data from a client who uses alcohol "to cope with stress." Which of the following questions should the nurse ask? A) "Do you see how your alcohol consumption affects your employment?" B) "Is your partner affected by your alcohol consumption?" C) "What daily activities are disrupted because of your alcohol consump- tion?" D) "Would you agree that stressful times in your life lead to increased alcohol consumption?": C) "What daily activities are disrupted because of your alcohol consumption?" The nurse is using an open-ended question, which is a therapeutic form of com- munication that can encourage the client to share information and to develop a rapport with the nurse. 13. A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take when caring for this client? A) Persuade the client to demonstrate acceptable behavior. B) Avoid talking about the client's past display of unacceptable behavior. C) Use countertransference to develop the therapeutic relationship. D) Remind the client of consequences for unacceptable behavior.: D) Remind the client of consequences for unacceptable behavior. Clients who have an antisocial personality disorder do not respect the rights of others. Therefore, the nurse should remind the client about which behaviors are acceptable and unacceptable and be prepared to administer consequences for unacceptable behavior. 14. A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? A) Flumazenil B) Vitamin K C) Acetylcysteine D) Naloxone: D) Naloxone The nurse should identify that naloxone is an opioid antagonist that is administered to treat the effects of opioid toxicity. Following administration, the nurse should monitor the client's respiratory and neurologic status. 15. A nurse is contributing to the plan of care for a client who has an anxiety disorder. Which of the following interventions should the nurse recommend be included in the plan? A) Help the client to identify situations that trigger his anxiety. B) Change the subject when the client has anxious feelings. C) Give detailed explanations of available activities. D) Encourage the client to determine his own daily schedules.: A) Help the client to identify situations that trigger his anxiety. The nurse should assist the client in identifying trigger situations to interrupt anxiety escalation in the future. 16. A nurse in a mental health facility is caring for a client who has schiz- ophrenia. The client becomes violent in the dayroom and begins throwing objects at staff and other clients. After calling for assistance, which of the following actions should the nurse take next? A) Obtain a prescription for mechanical restraints. B) Place the client in a monitored seclusion room. C) Tell the client calmly to sit down. D) Administer diazepam intramuscularly.: C) Tell the client calmly to sit down. When providing client care, the nurse should first use the least restrictive interven- tion. Therefore, the nurse should use verbal de-escalation techniques after calling for assistance for a client who is aggressive. 17. A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A) Keep the client's room dark at night. B) Alternate the client's caregivers on a routine basis. C) Stand in front of the client when speaking. D) Remove personal belongings from the client's room.: C) Stand in front of the client when speaking.