RN VATI Mental Health :RN VATI Mental Health 2019 Assessment: Questions & Answers Updated Version
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RN VATI Mental Health
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RN VATI Mental Health
A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan? (ANS - Provide the client with plastic eating utensils. -The client can use glass dishes and metal silverware to cause self harm, therefore, the nurse should...
RN VATI MENTAL HEALTH 2019 ASSESSMENT 1. A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan? - Provide the client with plastic eating utensils. Rationale: -The client can use glass dishes and metal silverware to cause self-harm , therefore, the nurse should arrange for the client to have only plastic products on their meal tray. 2. A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first? - Inform the client that this admission is confidential. Rationale: -According to evidence -based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse client relationship. This action establish es trust between the client and the nurse, which in turn decreases the client's anxiety level. 3. A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have I done any permanent damage to my body?" Which of the following re sponses should the nurse make? - You're afraid you have caused physical injury to yourself? Rationale: -Repeating the main idea of what the client has said, which will allow for clarification of any misunderstanding on the part of the client or the nurse. 4. A nurse i s caring for a client following a fire that destroyed her home and killed one of her children. The client is crying and does not make eye contact with the nurse. Which of the following questions should the nurse ask first? - Have you thought of harming you rself? Rationale: -The greatest risk to this client is self-harm due to the loss of her child and home, therefore, the first question the nurse should ask a client who is having a personal crisis is to determine if the client has suicidal ideation. If so, the nurse should take action to protect the client from self-
harm . 5. A nurse is checking laboratory values for a hospitalized young adult client who has bipolar disorder and is taking lithium. Which of the following values is the priority for the nurse to report to t he provider? - Serum creatinine 2.1 mg/dL -Reference range of 0.5 -1.2 mg/dL. 1 Rationale: The greatest risk to this client is decreased kidney function, which can cause an increase in the client's lithium level; therefore, this value is the priority for the nurse to r eport to the provider. The client’s lithium dosage might need to be modified based on this lab value. The cause of increased serum creatinine include dehydration as well as renal disorders. Lithium is contraindicated for clients who have severe renal diseas e, cardiac disease, or severe dehydration. 6. A nurse is providing information to a client who is seeking voluntary admission to a mental health facility. Which of the following information should the nurse include? - You will still need to give informed con sent for treatment after admission. Rationale: -A client who seeks voluntary admission to a mental health facility has the same rights as clients receiving any other kind of health care. The client will still need to give informed consent for treatment and therapies , such as electroconvulsive therapy. 7. A nurse is developing a plan of care for an adolescent client who has conduct disorder. Which of the following interventions should the nurse include in the plan? - Initiate a behavioral contract with the client. Rationale: -A client who has conduct disorder can demonstrate patterns of behavior that are aggressive, disrespectful of others’ rights, and can lead to injury of others. A behavioral contract helps to develop trust between the client and the nurse and emphasizes the client's responsibility to commit to work on changes in behavior. 8. A hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatment. One of the adult children is angry with the provider and blames the provider for their father's death. Which of the following defense mechanisms is the family member using? - Displacement Rationale: -When this family member uses displacement, they are transferring their feelings of anger to the provider so they do not have to cope with their own feelings of sadness and loss. 9. A nurse in an acute care facility is providing teaching for the adult child of an older adult client who is admitted with a urinary tract infection and delirium. The client has been living independentl y at home. Which of the following statements by the adult child demonstrates the teaching has been effective? - I expect that my father will no longer be confused when he is discharged. 10.A nurse is caring for a client who is experiencing a manic episode. W hich of the following actions should the nurse take first? - Encourage the client to rest each hour. 2 Rationale: -The greatest risk to this client is injury from exhaustion due to the manic phase, therefore, the priority action the nurse should take is to encourage t he client to rest for 3 -5mins every hour. 11. A nurse is leading a medication education group for several clients. A client who is sometimes violent becomes angry and begins yelling at others in the group. Which of the following actions should the nurse take? SATA - Move others away from the client. Offer the client a PRN dose of lorazepam. Ask the client open ended questions about the behavior. Rationale: -A large personal space should be maintained around the client who is angry. If the client's behavior continues to escalate, the nurse should move others away from the client for their safety. -Antianxiety medication can be used in conjunction with de -escalation techniques to prevent a violent episode. -Communication technique is nonthreatening and encourages the clien t to express their feelings. 12. A charge nurse is planning an in -service for a group of newly licensed nurses about the use of restraints. Which of the following information should the nurse include? - Record the client's behavior every 15mins while in restr aints. Rationale: -Complete a written record of the client's behavior every 15mins in the client's medical record while in restraints. The client should be considered for reintegration when they are able to follow commands and exhibit self -control of behavior. 13. A nu rse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect? - Dental caries Rationale: -Have dental caries and tooth erosion due to excessive exposure to stomach acid from frequent vomiting. 14. A nurse is providing teach ing to a client who has bipolar disorder and has been taking lithium for 4 months. The client's serum lithium levels are within the therapeutic range. Which of the following instructions should the nurse include to promote the maintenance of the therapeuti c lithium level? - Limit outdoor exercise during hot weather. Rationale: -Spending time outdoors during hot weather, especially if exercising, promoting dehydration and sodium loss through diuresis, which can increase lithium levels. Whenever the client exercises, develops diarrhea, vomits, or has any circumstance that can caus e dehydration, fluids and electrolytes must be replaced promptly. 3
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