ATI Nursing Detailed Answer Key Mental Health Progression Practice
1. A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
A. "We will call your family ...
lOMoAR cPSD|19334 6 ATI Nursing Detailed Answer Key Mental Health Progression Practice 1. A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make? A. "We will call your family in time for them to get here." Rationale: The nurse dismisses the client’s concerns and gives false reassurance. B. "I wonder if you are fearful of dying alone." Rationale: The nurse dismisses the client’s concerns and gives false reassurance. C. "I will make sure a staff member is in your room at all times." Rationale: The nurse dismisses the client’s concerns and gives false reassurance. D. "I will tell your family of your concern so that they can be here." Rationale: The nurse dismisses the client’s concerns and gives false reassurance. 2. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make? A. "It sounds like you're having a difficult time." Rationale: This therapeutic response is an open -ended, empathetic statement that encourages the client to talk. B. "Have you talked to your parents about this yet?" Rationale: This nontherapeutic response is focused inappropriately on the client's parents. It does not address the client's need to communicate or express feelings. C. "Why do you think you are so anxious?" Rationale: This nontherapeutic response can make the client feel defensive, and he might not be able to tell the nurse why. D. "How long has this been going on?" Rationale: This nontherapeutic response is a closed -ended statement that does not encourage the client to talk. 3. A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? A. A private room in a quiet location on the unit Rationale: A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can Page 1 Detailed Answer Key Mental Health Progression Practice be used for time-out during the day and to settle down to sleep at night. B. A semi -private room with a roommate who has a similar diagnosis Rationale: The client should not be given a semi -private room with a roommate who is also experiencing mania because the situation would be too stimulating for each of them. C. A private room close to the nursing station Rationale: The client should not be given a private room close to the nursing station because of the high level of activity in that area. D. A seclusion room until the client’s activity level becomes more subdued. Rationale: Legal and ethical guidelines require treatment in the least restrictive setting. Seclusion requires a provider’s s order and can only be used when there is a specific, documented need to do so. 4. A nurse is admitting a client who has experienced a weight lo ss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? A. Identify the client's nutritional status. Rationale: According to the nursing process, the nurse should perform an assessment first to gather enough data regarding nutritional status and other findings in order to plan, implement, and evaluate care. The assessment identifies client nutrition needs as well as complications the client might be experiencing related to the eating disorder. B. Request a mental health consult. Rationale: Requesting a mental health consult might be necessary but another aspect of care is the pri ority. C. Plan a therapeutic diet for the client. Rationale: Rationale C. Planning a therapeutic diet for the client will be necessary but another aspect of care is the priority. D. Provide a structured environment for the client. Rationale: It is important to provide a structured environment for the client regarding meals, times for weighing, and monitoring of eating, but another aspect of care is the priority. 5. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? A. Dysrhythmias Rationale: Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes, including prolonged QT interval, while taking haloperi dol. There Created on:02/05/2018 Page 2 Detailed Answer Key Mental Health Progression Practice is a risk for cardiac arrest due to torsades de pointes . B. Cataracts Rationale: The client who takes haloperidol is at risk for glaucoma, but cataracts are not an adverse effect. C. Pancreatitis Rationale: The client who takes haloperidol is at risk for hepatitis, but pancreatitis is not an adverse effect. D. Bleeding Rationale: The client who takes haloperidol does not have an increased risk for bleeding. 6. A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? A. "Of course people care. Your family comes to visit every day." Rationale: Trying to convince the client that his family members care about him is false reassurance that minimizes the feelings he just communicated. B. "Why do you feel that way?" Rationale: Asking the client a "why" question minimizes his feelings and is nontherapeutic. C. "Tell me who you think doesn't care about you." Rationale: By asking the client to tell what people don't care about him, the nurse is challenging the client's beliefs and changing the focus of the client away from his feelings and onto another subject. D. "I care about you, and I am concerned that you feel so sad." Rationale: This is an open -ended therapeutic statement that focuses on the client's feelings, shows empathy, and allows for further exploration of the client's belief that life is not worth living in order to keep the client safe from suicidal thoughts. 7. A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take? A. Instruct the client to sit down and stop pacing. Rationale: The client is experiencing severe or panic -level anxiety and in this condition has difficulty comprehending instructions. B. Allow the client to pace alone until physically tired. Rationale: Not intervening for the client's pacing and allowing it to continue could be a safety hazard for the client and other clients in the area. The nurse should take measures to reduce the client's anxiety.
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