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ATI RN MENTAL HEALTH
ONLINE PRACTICE 202 5 A
A school nurse is assessing a school aged 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)
- Clinging behaviors directed toward a teacher
- Increased time spent sleeping
- Intense focus on school work
- Lack of interest in an upcoming holiday - CORRECT ANSWER - Correct = 4. Lack of interest in an upcoming holiday The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events (e.g., Holidays) *PTSD manifestations seen in children include detachment or estrangement from others, difficulty sleeping/distressing dreams, difficulty concentrating on tasks A nurse is caring for a group of clients. Which of the following finding should the nurse report?
- A client who is taking clozapine and has a WBC count of 7,
- A client who is taking lamotrigine and has developed a rash
- A client who is taking valproate and has a platelet count of 150,
- A client who is taking lithium and has a lithium level of 1.2 - CORRECT ANSWER - Correct =
- A client who is taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life threatening adverse effect of the medication and report the finding immediately A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as contraindication for receiving clozapine?
- WBC count 2,
- Hgb 11.
- Platelets 150,
- RBC count 3.5 - CORRECT ANSWER - Correct - 1. WBC count 2, Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?
- "I'm relieved now that my financial affairs are in order."
- "It is easier to talk about my feelings now."
- "Suddenly I have enough energy to do anything I want."
- "Thank you for always taking such good care of me." - CORRECT ANSWER - Correct - 2. "It is easier to talk about my feelings now." When clients express their feelings, this indicates a positive treatment outcome
*The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that others cannot hear anything to reinforce reality. The nurse should ask the client if they are hearing voices to evaluate whether these are command hallucinations, which can place the client or others at risk for harm. The nurse should assist the client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to stop, which gives the client a sense of control A nurse is caring for a client who has impaired cognition A nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client Potential Intervention:
- When addressing the client, approach them from the front when possible
- Use a vest restrain to keep the client in a medical recliner
- Ensure the bed is kept at a working height for the nurse
- Provide the client with high-calorie protein drinks hourly
- Give directions to the client slowly and in a moderate tone of voice
- Decrease the sensory stimulation
- Keep the lights off in the client's bedroom and bathroom at night
- Assign the client to a room near the nurses' station Exhibit 1: Medical History Day 1, 0800: Client treated for UTI 8 months ago Day 3, 0830: Client fell getting out of bed to go to the ba - CORRECT ANSWER - Correct =
- When addressing the client, approach them from the front when possible = Anticipated.
*A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote aggressive behavior in the client.
- Use a vest restraint to keep the client in a medical recliner = Contraindicated. *The client has the right to be free from the use of restraints except in the case of an emergency.
- Ensure the bed is kept at a working height for the nurse = Contraindicated. *The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the client does fall.
- Provide the client with high-calorie protein drinks hourly = Nonessential. *This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has mania with this type of dietary supplement.
- Give directions to the client slowly and in a moderate tone of voice = Anticipated. *Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause the client to feel uncomfortable and can even cause feelings of anger.
- Decrease sensory stimulation = Anticipated. *A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair client safety.
- Keep the lights off in the client's bedroom and bathroom at night = Contraindicated. *This can increase the client's risk for falls. Keeping a light on can decrease wandering.
- Assign the client to a room near the nurses' station = Anticipated. *This promotes client safety by allowing staff to observe the client frequently. A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?
- Additional acute episodes of depression are unlikely following inpatient care.
- Early identification of changes, such as decreased social involvement, is important.
- Medication compliance will prevent further need for inpatient hospitalization.
A nurse in a community health center is teaching families of clients who have post traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?
- Repeatedly talks about the traumatic incident
- Sleeps excessively
- Experiences feelings of isolation
- Uses repetitive speech - CORRECT ANSWER - Correct = 3. Experiences feelings of isolation The nurse should expect clients who have PTSD to feel estranged/detached from others, avoid discussing the traumatic event, have difficulty sleeping, hypervigilance, and verbal aggression A nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take?
- Place the client in mechanical restraints.
- Ensure security personnel are available in the background to assist if the client's behavior escalates.
- Ask the client, "Why are you so upset?"
- Remain within arms length of the client in case they need to be quickly removed from the room. - CORRECT ANSWER - Correct = 2. Ensure security personnel are available in the background to assist if the client's behavior escalates. The nurse should attempt to de-escalate the situation using less restrictive techniques, such as therapeutic communication, decreasing stimulation, or pharmacological measures. The client is exhibiting manifestations of anger and agitation that often precede a violent event. While the nurse should attempt to de-escalate the situation, safety measures should be in place. The nurse should verify that assistance is available if the client becomes violent. Security should be kept out of the client's line of sight until they are needed to avoid escalating the situation.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?
- A client refuses electroconvulsive therapy after signing the consent form.
- A client who was voluntarily admitted left the unit against medical advice.
- A client was administered one-half of the prescribed dose of medication.
- A client was placed in restraints after attempts to de-escalate aggressive behaviors failed. - CORRECT ANSWER - Correct = 3. A client was administered one-half of the prescribed dose of medication. An incident report is a recording of any occurrence that does not meet the standard of care. The nurse should report medication errors using the facility's incident or occurrence form. A nurse in a community health center is working with a group of clients who have post traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members?
- Response prevention
- Guided imagery
- Aversion therapy
- Light therapy - CORRECT ANSWER - Correct = 2. Guided imagery Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder. *Response Prevention = Used in the treatment of Compulsive Behavior *Aversion Therapy = A negative feedback method used to treat Alcohol Use Disorder, Violent Behavior, and Self Mutilation *Light Therapy = Used in the treatment of Seasonal Affective Disorder
- Move the client who has bipolar disorder to a private room.
- Administer sleep medication to the client who has bipolar disorder.
- Move the client who has severe depression to a private room.
- Administer sleep medication to the client who has severe depression. - CORRECT ANSWER
- Correct = 1. Move the client who has bipolar disorder to a private room. Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room. *Clients who have severe depression are often at risk for self-harm and feel isolated. Therefore, the nurse should not move this client to a private room. A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
- Panic
- Moderate
- Severe
- Mild - CORRECT ANSWER - Correct = 4. Mild The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information. *Moderate, Severe, and Panic levels of anxiety will interfere with the client's ability to concentrate and process information A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?
- Weight gain
- Tinnitus
- Tachycardia
- Increased salivation - CORRECT ANSWER - Correct = 3. Tachycardia Tachycardia, Weigh Loss, and Dry Mouth are all adverse effects of methylphenidate. A nurse is discussing a 12 steps program with a client who has alcohol use disorder and is in an acute facility undergoing detoxification. Which of the following information should the nurse include in the teaching?
- The program will help the client accept responsibility for the disorder.
- The client should obtain a sponsor before discharge for an increased chance of recovery.
- The client will need to identify individuals who have contributed to the disorder.
- The program will need a prescription from the client's provider prior to attendance. - CORRECT ANSWER - Correct = 2. The client should obtain a sponsor before discharge for an increased chance of recovery. The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program. *The nurse should teach the client that they cannot blame others for contributing to their disorder. The program will have the client identify individuals that they have harmed because of the disorder. The nurse should teach the client that they are weak in regards to alcohol and therefore not responsible for the disorder, but they are responsible for their individual recovery. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?
- Encourage the client to participate in group therapy.
*Suspicious of Others, Project Blame onto Others, Hostile and Violent: Features of Paranoid Personality Disorder *Grandiosity, Exploitive, Filled with Rage, and Sensitive to Criticism: Features of Narcissistic Personality Disorder 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?
- "Why do you think you deserve this punishment?"
- "Don't worry about being punished by God."
- "Let's talk about what is upsetting you."
- "You shouldn't say things that will upset you so much." - CORRECT ANSWER - Correct = 3. "Let's talk about what is upsetting you." The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling. A nurse is preparing to administer diazepam 7.5mg IV Bolus to a client for alcohol withdrawal. Available is diazepam injection 5mg/1mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - CORRECT ANSWER - Correct = 1.5mL Follow these steps for the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) XmL = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) X mL = 1mL/5mg
Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. XmL = 1mL/5mg x 7.5mg/ Step 4: Solve for X.--> 7.5mg Divided by 5mg XmL = 1. Step 5: Round if necessary. Step 6: Determine whether the amount to administer makes sense. If there are 5 mg/mL and the prescription reads 7.5 mg, it makes sense to administer 1.5 mL. The nurse should administer diazepam 1.5 mL IV bolus. A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?
- Slow onset
- Aphasia
- Confabulation
- Easily distracted - CORRECT ANSWER - Correct = 4. Easily Distracted Extreme distractibility and acute onset is a hallmark manifestation of delirium. *Slow, Progressive Decline, Aphasia, and Confabulation are all manifestations of Dementia A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the follow statements indicates that the client is at risk for complicated grief?
- "I wish I had been nicer and more generous with my wife before she died."
- "I told my wife to go to the doctor, but she wouldn't listen to me."
- "I think about my wife all the time when I go on outings with my family."
The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram. *The purpose of ECT is to induce a short seizure by stimulating the brain with an electrical current *The client will receive anesthetic and paralytic medications immediately prior to the procedure to prevent severe muscle contractions induced by the seizure *Temporary Disorientation, Confusion, Possible Memory Deficits are all expected adverse effects of ECT A nurse in a provider's office is collecting a health history from the guardian of a school age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?
- Reduced appetite
- Fatigue
- Dark urine
- Sweating - CORRECT ANSWER - Correct = 3. Dark urine The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure and death. Therefore, this is the nurse's priority finding. 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?
- Obsessive attention to detail
- Inability to sleep
- Reports of fatigue
- Isolation from others - CORRECT ANSWER - Correct = 2. Inability to sleep
During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding. A nurse on an acute mental health facility is receiving a change of shift report for four clients. Which of the following clients should the nurse assess first?
- A client who does not recognize familiar people
- A client who cannot verbalize their needs
- A client who is awake and disoriented at night
- A client who is experiencing delusions of persecution - CORRECT ANSWER - Correct = 4. A client who is experiencing delusions of persecution The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first. 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?
- Fear of abandonment
- Motor and verbal tics
- Hostile behavior
- Language delay - CORRECT ANSWER - Correct = 4. Language Delay The nurse should identify that language delays are a manifestation of autism spectrum disorder. *Fear of Abandonment = Manifestation of Separation Anxiety Disorder
- Assertive community treatment - CORRECT ANSWER - Correct = 4. Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy. A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?
- "If you do my homework for me, I won't bother you for the rest of the day."
- "Mom is always upset."
- "It's not the children's fault. It's mine."
- "It's your fault that we're having problems as a family." - CORRECT ANSWER - Correct = 1. "If you do my homework for me, I won't bother you for the rest of the day." This is an example of manipulative behavior. It is an example of manipulation when the family member uses a behavior to get what they desire rather than directly asking for what they want. A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?
- A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners.
- A client who has depression reports having a lack of interest in assisting their partner in the care of their children.
- A client who has borderline personality disorder threatened to harm their roommate.
- An adolescent client who has anorexia nervosa has a BMI of 17. - CORRECT ANSWER - Correct = 3. A client who has borderline personality disorder threatened to harm their roommate.
Manifestations of borderline personality disorder include disturbed interpersonal relationships accompanied by threats and other-directed violence. While it is important for the nurse to maintain the client's confidentiality, on occasions when another individual's life might be in danger, the nurse is required by law to report it to authorities. *The nurse has the duty to maintain confidentiality regarding the client's conversations with the nurse. Since genital herpes simplex virus is not a condition that needs to be reported, the nurse is not obligated to report the infection. The nurse should encourage the client to contact the client's sexual partners to inform them of the need to obtain testing and treatment if necessary. A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?
- Encourage the parents to avoid discussing the death with their other children to protect their feelings.
- Recommend each parent grieve in private to avoid hindering each other's healing.
- Suggest forming a weekly support group for parents who have experienced the death of a child.
- Advise the parents to begin counseling if they are still grieving in a few months. - CORRECT ANSWER - Correct = 3. Suggest forming a weekly support group for parents who have experienced the death of a child. Support groups are a positive resource in the process of recovery for parents following the death of a child. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?
- Encourage expression of feelings.
- Support the child's attendance at an assertiveness training group.
