ATI Mental Health Practice A

ATI Mental Health Practice A 1. A nurse is collecting data from a client who is experiencing alcohol with- drawal. Which of the following manifestations should the nurse expect?: Di- aphoresis The nurse should expect a client who is experiencing alcohol withdrawal to expe- rience diaphoresis, or increased sweating. 2. A nurse in a long-term care center is caring for an adult client who has Alzheimer's disease and whose partner died several years ago. The client appears upset and asks the nurse when his partner will visit again. The nurse states, "It seems like you are feeling lonely. Let's take a walk outside and talk." Which of the following communication strategies is the nurse using?: Validation therapy The nurse is using validation therapy as a strategy to communicate with the client. This strategy validates the client's feelings and emotions, even when they don't coincide with reality. The nurse should also attempt to integrate redirection techniques without the client realizing he is being redirected. 3. A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching?: "The voices you have been hearing should decrease" The nurse should instruct the client that hallucinations and agitated behavior, which are positive symptoms of schizophrenia, are targeted by conventional antipsychot- ic agents, such as chlorpromazine. 4. A nurse is reinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following state- ments should the nurse identify as an indication that the client understands the information?: "I should expect some improvement of my symptoms in about 10 days." The nurse should instruct the client to expect some improvement of symptoms after 7 to 10 days. However, it takes 2 to 4 weeks for buspirone to reach its full effect. 5. A nurse is caring for a client who has major depressive disorder (MDD). The client states, "I have nothing to live for anymore. I just can't go on." Which of the following responses should the nurse make?: "Are you thinking about ending your life?" The nurse should identify that this client's safety is at risk. The client's statement is an overt statement that indicates hopelessness, which increases the risk of suicide for a client who has MDD. It is imperative that the nurse immediately evaluate the client for suicidal ideation. 6. A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty staying seated and states loudly to the therapist ," I know more than you do about the people in this room!" The nurse should identify that which of the following findings is the likely explanation for the client's behavior?: Hypomania The nurse should suspect hypomania as the likely cause of the client's current behavior and investigate these actions further after calmly escorting the client from the therapy session. Clients who have hypomania exhibit excessive energy and a decreased need for sleep. These clients are easily distracted in a group setting and have a pretentious, grandiose sense of self. 7. A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statements should the nurse make to gather information about the client's ability to think abstractly?: "How is an orange similar to an apple?" Asking the client to explain similarities between objects or to explain the meaning of a common proverb or figure-of-speech tests the client's ability to think abstractly. 8. A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting behaviors at home. Which of the following actions should the nurse instruct the parent to take?: Initiate a point system for the child. The nurse should instruct the parent to use tokens or points to reward desired behaviors and reduce maladaptive behaviors. A point system provides an incentive for the child to increase acceptable behaviors. 9. A nurse is collecting data from a client who is having difficulty coping with the death of his child. Which of the following questions by the nurse is the priority?: "Do you think about harming yourself?" The nurse should identify that the greatest risk to this client is self-injury from suicide. Therefore, the priority intervention is to ensure the client's safety. The best way the nurse can accomplish that at this time is to determine if the client has thoughts of self-harm. 10. A nurse is reinforcing teaching about though stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions?: "I will snap a rubber band on my wrist when I feel anxious about riding in a car." This statement describes thought stopping, which is used to interrupt a client's negative thought with a distraction. 11. A nurse is assisting the charge nurse with the preparation for an in-ser- vice about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence?: A nurse does not notify the provider of a change in condition for a client who has schizophrenia. Negligence is the failure to act in a manner which follows the standard of care. The nurse should inform the provider of any changes in a client's condition. Failure to do so is considered negligence. 12. A nurse in a provider's office is collecting data from an older adult client whose adult child reports that she "seems confused and can't seem to remember much."Which of the following findings should lead the nurse to suspect delirium?: The client's level of consciousness changes during the interview. Delirium can rapidly alter the client's level of consciousness, which can manifest as agitation or stupor. Therefore, the nurse should suspect that this client is experiencing delirium. 13. A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She states to the nurse, "I am so angry that my doctor didn't take better care of me and my baby." Which of the following responses should the nurse make?: "It is important to share what you are feeling, even if it is anger." The nurse is encouraging the client to discuss her perception of the loss, which is a therapeutic communication technique. It is helpful to acknowledge that anger is an expected reaction to loss and encourage the client to verbalize her feelings. 14. A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the fol- lowing interventions should the nurse include in the plan to address limit setting?: Establish and explain consequences for the client's behavior. The nurse should communicate desired behavior and expectations as well as detailed consequences for not meeting those expectations to a client who has borderline personality disorder. These expectations and consequences should be included in the plan of care when addressing limit setting with the client. 15. A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take?: Encourage the client to develop a safety plan. The nurse should encourage the client to develop a safety plan to aid in escaping further violence if necessary. 16. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client's use of this substance?: Hypertension Cocaine is a central nervous system stimulant. Therefore, hypertension is an expected finding. 17. A nurse in a mental health facility is caring for a client who has dementia. The client's agitation is increasing. Which of the following actions should the nurse take first?: Offer diversionary activities When providing client care, the nurse should first use the least restrictive interven- tion. Therefore, the nurse should offer diversionary activities to distract the client and redirect energy into more appropriate behaviors. 18. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first?: Determine the client's intentions.