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Questions and Answers
Which suggestions should the nurse make to decrease the client's risk for injury? (Select all that apply)
Which suggestions should the nurse make to decrease the client's risk for injury? (Select all that apply)
What action should the nurse take regarding the client's nutrition concerns?
What action should the nurse take regarding the client's nutrition concerns?
Which findings should the nurse expect for a client with delirium related to an acute UTI? (Select all that apply)
Which findings should the nurse expect for a client with delirium related to an acute UTI? (Select all that apply)
Which statement is appropriate for the nurse to include regarding substance use in older adults?
Which statement is appropriate for the nurse to include regarding substance use in older adults?
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What findings should the nurse expect for a client experiencing alcohol withdrawal? (Select all that apply)
What findings should the nurse expect for a client experiencing alcohol withdrawal? (Select all that apply)
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What is the priority intervention for a client experiencing benzodiazepine withdrawal?
What is the priority intervention for a client experiencing benzodiazepine withdrawal?
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Which of the following statements by the newly licensed nurse indicates an understanding of the teaching regarding mental status exams? (Select all that apply)
Which of the following statements by the newly licensed nurse indicates an understanding of the teaching regarding mental status exams? (Select all that apply)
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Which action should the nurse include as a psychobiological intervention for a client with a mental health disorder?
Which action should the nurse include as a psychobiological intervention for a client with a mental health disorder?
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Which action should the nurse identify as the priority when conducting an initial client interview?
Which action should the nurse identify as the priority when conducting an initial client interview?
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When assessing a stuporous client, which finding should the nurse expect?
When assessing a stuporous client, which finding should the nurse expect?
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Which information should be included in the discussion about the DSM-5? (Select all that apply)
Which information should be included in the discussion about the DSM-5? (Select all that apply)
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Which client requires a temporary emergency admission?
Which client requires a temporary emergency admission?
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The nurse's decision to put a client who has a psychotic disorder in seclusion overnight demonstrates which tort?
The nurse's decision to put a client who has a psychotic disorder in seclusion overnight demonstrates which tort?
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What action should the nurse take when a client mentions hiding a sharp knife?
What action should the nurse take when a client mentions hiding a sharp knife?
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Which statements should the nurse document about a client in mechanical restraints? (Select all that apply)
Which statements should the nurse document about a client in mechanical restraints? (Select all that apply)
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What action should the nurse take first when witnessing a newly licensed nurse discussing a client's hallucinations?
What action should the nurse take first when witnessing a newly licensed nurse discussing a client's hallucinations?
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Which response should the nurse make to the parents of a child demonstrating behavioral changes?
Which response should the nurse make to the parents of a child demonstrating behavioral changes?
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What defense mechanism is the client exhibiting when claiming to cough due to a cold?
What defense mechanism is the client exhibiting when claiming to cough due to a cold?
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Which level of anxiety is the client experiencing with a respiratory rate of 30/min and feelings of nervousness?
Which level of anxiety is the client experiencing with a respiratory rate of 30/min and feelings of nervousness?
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Which actions should the nurse take to assist a client experiencing moderate anxiety? (Select all that apply)
Which actions should the nurse take to assist a client experiencing moderate anxiety? (Select all that apply)
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Which statement should the nurse make to a client at risk for suicide following the death of a spouse?
Which statement should the nurse make to a client at risk for suicide following the death of a spouse?
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Which characteristic of a nurse-client relationship should be included in the discussion with a newly licensed nurse? (Select all that apply)
Which characteristic of a nurse-client relationship should be included in the discussion with a newly licensed nurse? (Select all that apply)
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Which action indicates transference behavior during a therapeutic relationship?
Which action indicates transference behavior during a therapeutic relationship?
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Which action should the nurse include in the termination phase of a nurse-client relationship?
Which action should the nurse include in the termination phase of a nurse-client relationship?
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What statement should the nurse make when orienting a new client about community meetings?
What statement should the nurse make when orienting a new client about community meetings?
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Which client should the nurse visit first?
Which client should the nurse visit first?
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Which intervention should the nurse plan as a method of tertiary prevention for depression among older adults?
Which intervention should the nurse plan as a method of tertiary prevention for depression among older adults?
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Which services are provided by a community mental health program? (Select all that apply)
Which services are provided by a community mental health program? (Select all that apply)
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Which follow-up care should the nurse suggest for a client requiring supervision?
Which follow-up care should the nurse suggest for a client requiring supervision?
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Which client should be considered for referral to an assertive community treatment (ACT) group?
Which client should be considered for referral to an assertive community treatment (ACT) group?
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Which client statement indicates understanding of classical psychoanalysis?
Which client statement indicates understanding of classical psychoanalysis?
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Which statement indicates understanding free association as a therapeutic tool?
Which statement indicates understanding free association as a therapeutic tool?
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Which techniques should be included in the cognitive reframing plan of care? (Select all that apply)
Which techniques should be included in the cognitive reframing plan of care? (Select all that apply)
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What type of treatment is disulfiram (used for alcohol use disorder) an example of?
What type of treatment is disulfiram (used for alcohol use disorder) an example of?
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Which action implements systematic desensitization for a client with an elevator phobia?
Which action implements systematic desensitization for a client with an elevator phobia?
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Which action demonstrates democratic leadership in a group focused on conflict resolution?
Which action demonstrates democratic leadership in a group focused on conflict resolution?
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What concept is demonstrated when two group members discuss a shared interest during a meeting?
What concept is demonstrated when two group members discuss a shared interest during a meeting?
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Which dysfunctional behavior is the adolescent son demonstrating by planning to manipulate his sibling?
Which dysfunctional behavior is the adolescent son demonstrating by planning to manipulate his sibling?
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Which role should the nurse identify as an individual role within a group?
Which role should the nurse identify as an individual role within a group?
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What information should be included in an educational seminar on stress?
What information should be included in an educational seminar on stress?
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Which effects are identified as acute stress responses?
Which effects are identified as acute stress responses?
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Which of the following client statements indicates understanding of the teaching? (Select all that apply)
Which of the following client statements indicates understanding of the teaching? (Select all that apply)
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Which of the following recommendations should the nurse make to promote a change in the client's situation?
Which of the following recommendations should the nurse make to promote a change in the client's situation?
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When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding?
When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding?
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Which of the following client statements indicates understanding of the ECT teaching?
Which of the following client statements indicates understanding of the ECT teaching?
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Which statement indicates an understanding of TMS?
Which statement indicates an understanding of TMS?
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Which findings should the nurse expect after an ECT procedure? (Select all that apply)
Which findings should the nurse expect after an ECT procedure? (Select all that apply)
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Which of the following should the nurse include in the discussion about ECT indications?
Which of the following should the nurse include in the discussion about ECT indications?
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What adverse effects should the nurse monitor for following surgical implantation of a VNS device? (Select all that apply)
What adverse effects should the nurse monitor for following surgical implantation of a VNS device? (Select all that apply)
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What underlying reason causes repetitive behavior in a client with OCD?
What underlying reason causes repetitive behavior in a client with OCD?
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Which action should the nurse take for a client experiencing a panic attack?
Which action should the nurse take for a client experiencing a panic attack?
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Which findings should the nurse expect in a client with generalized anxiety disorder? (Select all that apply)
Which findings should the nurse expect in a client with generalized anxiety disorder? (Select all that apply)
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What is the first action a nurse should take for a client with body dysmorphic disorder?
What is the first action a nurse should take for a client with body dysmorphic disorder?
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What statement should the nurse make to a client with acute stress disorder experiencing severe anxiety?
What statement should the nurse make to a client with acute stress disorder experiencing severe anxiety?
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Which findings should the nurse expect in a client with PTSD? (Select all that apply)
Which findings should the nurse expect in a client with PTSD? (Select all that apply)
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What strategies should a nurse use to help prevent developing a trauma-related disorder? (Select all that apply)
What strategies should a nurse use to help prevent developing a trauma-related disorder? (Select all that apply)
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What information should a nurse expect to collect from a client who has ASD?
What information should a nurse expect to collect from a client who has ASD?
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Which finding indicates derealization in a client?
Which finding indicates derealization in a client?
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What intervention should the nurse include in the care plan for a client with dissociative fugue?
What intervention should the nurse include in the care plan for a client with dissociative fugue?
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Which factors put a client with a history of chronic asthma at risk for depression? (Select all that apply)
Which factors put a client with a history of chronic asthma at risk for depression? (Select all that apply)
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What is the nurse's priority action for a client with major depressive disorder and comorbid anxiety disorder?
What is the nurse's priority action for a client with major depressive disorder and comorbid anxiety disorder?
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What indicates understanding of PMDD teaching?
What indicates understanding of PMDD teaching?
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What indicates understanding about the care of a client with MDD?
What indicates understanding about the care of a client with MDD?
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What findings indicate dysthymic disorder?
What findings indicate dysthymic disorder?
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Which interventions should the nurse include in the plan of care for a client experiencing a manic episode? (Select all that apply)
Which interventions should the nurse include in the plan of care for a client experiencing a manic episode? (Select all that apply)
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Which statement indicates understanding of ECT for bipolar disorder?
Which statement indicates understanding of ECT for bipolar disorder?
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What response should the nurse give to a client who expresses a need to give money away?
What response should the nurse give to a client who expresses a need to give money away?
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What is the priority nursing action for a client with bipolar disorder?
What is the priority nursing action for a client with bipolar disorder?
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Which information should the nurse include in the teaching on relapse prevention for bipolar disorder? (Select all that apply)
Which information should the nurse include in the teaching on relapse prevention for bipolar disorder? (Select all that apply)
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What should the nurse say to a client experiencing auditory hallucinations?
What should the nurse say to a client experiencing auditory hallucinations?
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Which findings indicate positive symptoms in a client with schizophrenia? (Select all that apply)
Which findings indicate positive symptoms in a client with schizophrenia? (Select all that apply)
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Which statement indicates depersonalization in a client?
Which statement indicates depersonalization in a client?
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What action should the nurse take if a client reports hearing voices instructing harmful behavior?
What action should the nurse take if a client reports hearing voices instructing harmful behavior?
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What action should the nurse take when a client with schizophrenia stops focusing on questions and appears to talk to themselves?
What action should the nurse take when a client with schizophrenia stops focusing on questions and appears to talk to themselves?
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What statement indicates understanding of personality disorder care?
What statement indicates understanding of personality disorder care?
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What statement would a client with avoidant personality disorder be likely to make?
What statement would a client with avoidant personality disorder be likely to make?
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The client with borderline personality disorder expresses strong feelings towards different nurses. What is this an example of?
The client with borderline personality disorder expresses strong feelings towards different nurses. What is this an example of?
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What findings should the nurse expect when evaluating a client with antisocial personality disorder? (Select all that apply)
What findings should the nurse expect when evaluating a client with antisocial personality disorder? (Select all that apply)
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What should the nurse teach a client who has early-stage Alzheimer's disease about donepezil?
What should the nurse teach a client who has early-stage Alzheimer's disease about donepezil?
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Study Notes
Mental Status Exams
- Cognitive ability assessment can involve asking clients to count backward by sevens.
- Assessment of affect focuses on observing the client's facial expressions.
- Language ability can be evaluated by asking clients to write a sentence.
Psychobiological Interventions
- Monitoring clients for medication adverse effects is a crucial psychobiological intervention.
Initial Client Interview
- Prioritize understanding the client's perception of their mental health status during the initial interview.
Assessment of Stupor
- A stuporous client may only arouse briefly in response to vigorous stimuli like a sternal rub.
DSM-5 Characteristics
- The DSM-5 establishes diagnostic criteria for mental health disorders and aids in care planning.
- It does not provide client education handouts or recommended pharmacological treatments.
Temporary Emergency Admission
- Clients exhibiting harmful behavior, such as assault, need temporary emergency admission.
Seclusion and Torts
- Placing a client in seclusion without just cause could be considered false imprisonment.
Confidentiality and Client Safety
- Information regarding a client hiding a weapon must be reported for the safety of all involved.
Documentation for Clients in Restraints
- Notes on hydration, patient behavior, and medication administration are essential for documenting clients in restraints.
Addressing Confidentiality Violations
- First action if a nurse discusses a client's hallucinations inappropriately is to stop the conversation.
Parent Reassurance Techniques
- Addressing parental concerns involves acknowledging the parents' worries and discussing specific concerns.
Defense Mechanisms
- A client denying symptoms of lung cancer demonstrates denial as a defense mechanism.
Anxiety Levels in Clients
- A client showing rapid breathing and nervousness is likely experiencing moderate anxiety.
Managing Moderate Anxiety
- Engaging the client in discussions about effective coping mechanisms is important.
Supporting Clients at Risk for Suicide
- Validate the client's feelings of loss to create a supportive environment for discussion.
Characteristics of Therapeutic Relationships
- Effective nurse-client relationships are goal-directed, encourage behavioral change, and have a termination date.
Understanding Transference Behavior
- Clients may display transference by projecting feelings related to past relationships onto their current nurse.
Termination Phase of Nurse-Client Relationship
- Discussing how to apply new behaviors after therapy is part of the termination phase.
Community Meeting Structure
- Community meetings allow clients to discuss shared challenges and treatment plans, often with staff involvement.
Client Prioritization in Community Mental Health
- Clients expressing thoughts of self-harm should be prioritized for immediate follow-up.
Tertiary Prevention for Depression
- Rehabilitation programs aimed at reducing the effects of depression serve as a tertiary prevention method.
Community Mental Health Facility Services
- Facilities provide educational groups, medication dispensing, individual counseling, and family therapy.
Post-Hospitalization Care Planning
- Partial hospitalization programs are an effective follow-up care strategy for clients needing supervision.
Assertive Community Treatment Referrals
- Clients who struggle to attend appointments consistently can benefit from assertive community treatment groups.
Psychoanalysis Understanding
- Clients understand that psychoanalysis will explore past relationships and experiences that contribute to current issues.
Free Association Technique
- Instructing clients to verbalize thoughts as they arise reflects understanding of the free association technique.
Cognitive Reframing Techniques
- Techniques like priority restructuring, monitoring thoughts, and journaling are key for cognitive reframing strategies.
Aversion Therapy with Disulfiram
- Disulfiram treatment for alcohol use disorder exemplifies aversion therapy by inducing nausea when alcohol is consumed.
Systematic Desensitization Approach
- Gradual exposure to feared situations paired with relaxation techniques defines systematic desensitization.
Democratic Leadership in Groups
- Democratic leadership encourages group participation and collaboration to navigate conflict resolution.
Group Process Dynamics
- Discussions unrelated to the group's focus could indicate a hidden agenda among group members.
Identifying Manipulation in Family Dynamics
- Adolescent behavior aimed at gaining favor through manipulation illustrates dysfunctional family interaction patterns.
Individual Roles within Groups
- Individuals may sometimes take on unproductive roles, such as bragging about personal achievements.
Stress Understanding and Effects
- Chronic stress leads to distress, while acute stress can manifest as increased blood pressure and panic attacks.
Teachings on Stress Reduction Techniques
- Cognitive reframing is a valuable technique in stress management, helping clients reframe irrational thoughts.
Promoting Assertiveness in Client Situations
- Encouraging clients to use assertive communication techniques empowers them to handle stressful situations effectively.
Effective Communication Techniques
- Clients should express their feelings constructively, focusing on their experiences rather than blaming others.### ECT and TMS Treatment
- ECT often utilized for depression before considering medications.
- ECT may lead to remission of depressive symptoms through a series of treatments.
- Muscle relaxants administered during ECT to prevent injury.
TMS Treatment Understanding
- TMS suitable for clients with mood disorders, not schizophrenia spectrum disorders.
- Daily TMS sessions recommended initially for several weeks.
- TMS treatments typically last between 5-10 minutes.
Observing Post-ECT Findings
- Expected findings after ECT include memory loss, nausea, and confusion.
- Hypotension and paralytic ileus are less common after ECT.
ECT Indications
- ECT indicated for bipolar disorder with rapid cycling among others.
- Not generally recommended for borderline personality disorder or dysphoric disorder.
VNS Device Monitoring
- Monitor for adverse effects like voice changes, dysphagia, and neck pain post-surgery.
Compulsive Behavior in OCD
- Repetitive behaviors in OCD, such as applying and removing makeup, are driven by anxiety reduction.
Panic Attack Care
- Nurse's priority is to stay present with the client experiencing a panic attack without overwhelming them.
Generalized Anxiety Disorder Assessment
- Expect findings such as persistent excessive worry, restlessness, and a need for reassurance.
Body Dysmorphic Disorder Care
- Initial step includes assessing the client’s risk for self-harm.
Acute Stress Disorder Communication
- Encourage the client to express their feelings, fostering open communication.
PTSD Symptoms
- Anticipate difficulties in concentration, negative self-image, and recurring nightmares in PTSD patients.
Strategies to Prevent Trauma-Related Disorders
- Essential strategies include taking breaks for hydration and food, debriefing with colleagues, and utilizing counseling services.
Acute Stress Disorder Admission History
- Clients may express a sense of unreality about traumatic events.
Identifying Derealization
- Clients experiencing derealization may perceive surroundings as distorted or distant.
Dissociative Fugue Care Interventions
- Grounding techniques should be prioritized to assist clients recovering from dissociative fugue.
Depression Risk Factors
- Factors that increase depression risk include age, gender, chronic health conditions (like asthma), and marital status.
Priority Care for Major Depressive Disorder
- The highest priority is ensuring client safety through close observation.
Understanding Premenstrual Dysphoric Disorder
- Clients should acknowledge the rapid mood swings associated with PMDD.
Major Depressive Disorder Suicide Risk
- Increased suicide risk during early weeks of depression episode.
Dysthymic Disorder Manifestations
- A minimum of two years of depressive symptoms is characteristic of dysthymic disorder.
Managing Bipolar Disorder Episodes
- Include concise explanations, establish limits, and maintain a firm communication approach during manic episodes.
ECT for Bipolar Disorder
- ECT is effective for those experiencing severe mania.
Addressing Client’s Generosity during Mania
- Recognize and decline inappropriate gifts from clients during manic episodes.
Priority Actions in Bipolar Disorder
- Monitoring for escalating behavior is crucial during care.
Relapse Prevention in Bipolar Disorder
- Important indicators for relapse include difficulty sleeping and participation in therapy.
Communicating with Hallucinating Clients
- Engage in therapeutic communication to understand the nature of auditory hallucinations.
Positive Symptoms of Schizophrenia
- Positive symptoms include hallucinations, delusions, and abnormal behavioral responses.
Depersonalization in Schizoaffective Disorder
- A sense of being no one represents depersonalization.
Responding to Threatening Hallucinations
- Implement one-to-one observation for clients expressing intent to harm.
Social Engagement in Schizophrenia
- Understand and validate clients' visual perceptions during episodes.
Personality Disorder Care Principles
- Setting clear limits is key to managing clients with personality disorders effectively.
Avoidant Personality Disorder Characteristics
- Fear of abandonment is a defining trait of avoidant personality disorder.
Borderline Personality Disorder Defense Mechanism
- "Splitting" often manifests as dramatic shifts in interpersonal relationships.
Antisocial Personality Disorder Assessment
- Anticipate manipulative behaviors and boundary-testing among clients.
Donepezil for Alzheimer’s Disease
- Donepezil can slow cognitive decline in early-stage Alzheimer's patients.
Safety Measures for Clients with Alzheimer's
- Recommendations include installing childproof locks and placing mattresses on the floor to prevent falls.
Addressing Caregiver Concerns
- Provide resources for respite care to support primary caregivers of clients with dementia.
Delirium Related to UTI
- Anticipate personality changes and hallucinations when assessing delirium.
Substance Use in Older Adults
- Increased risk of substance use can follow retirement, highlighting the need for preventative measures.
Alcohol Withdrawal Symptoms
- Expect to see fine tremors, restlessness, and vomiting as signs of alcohol withdrawal.
Benzodiazepine Withdrawal Priority
- Prioritize implementing seizure precautions for clients undergoing benzodiazepine withdrawal.
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Test your knowledge on mental status exams with this engaging ATI Mental Health 2023 quiz. Answer questions that cover key concepts necessary for understanding mental health assessments, including cognitive ability, affect, and language skills. Perfect for newly licensed nurses looking to improve their expertise in the field.