A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "To asse... ss cognitive ability, I should ask the client to count backward by 7." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises D. "To assess remote memory, I should have the client repeat a list of objects." Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises D. Monitor the client for adverse effects of medications. Assisting with systematic desensitization therapy is a cognitive and behavioral. Teaching appropriate coping mechanisms is a counseling or health teaching. Assessing for comorbid health conditions is health promotion and maintenance. D. Monitoring for adverse effects of medications is an example of a psychobiological intervention. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action? A. Respect the client's need for personal space. B. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises B. Identify the client's perception of her mental health status. A. Appropriate, but not highest priority. B. Assessment is the priority action when taking the nursing process approach. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history. C. Appropriate, but not highest priority. D. Appropriate, but not highest priority. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following is an expected finding? A. The client arouses briefly in response to a sternal rib. B. The client has a Glasgow Coma Scale score less than 7. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises A. The client arouses briefly in response to a sternal rib. A. A client who is stuporous requires vigorous or painful stimuli to elicit a response. B. <7 on GCS indicates comatose, not stuporous, level of consciousness. C. Abnormal posturing = comatose. D. Stuporous /= alert. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following is appropriate to include in the discussion? (SATA) A. The DSM-5 is used to identify mental health disorders. B. The DSM-5 establishes diagnostic criteria. C. The DSM-5 indicates recommended pharmacological treatment. D. The DSM-5 assists nurses in planning care. E. The DSM-5 indicates expected assessment findings. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises A, B, D, E. The DSM-5 is used as a diagnostic tool, establishes diagnostic criteria, used by nurses to plan, implement, and evaluate care, and identifies expected findings for mental health disorders. It does not indicate pharmacological treatment. ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises Which of the following is an example of a client who requires emergency admission to a mental health facility? A. A client with schizophrenia who has frequent hallucinations. B. A client with symptoms of depression who attempted suicide a year ago. C. A client with borderline personality disorder who assaulted a homeless man with a metal rod. D. A client with bipolar disorder who paces quickly down the sidewalk while talking to himself. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises C. A client with borderline personality disorder who assaulted a homeless man with a metal rod. Hallucinations, depression, and/or pacing does not constitute clear reason for emergency commitment. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises A client tells a student nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to holding the knife. B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. D. Report the incident, but do not inform the client of the intention to do so. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. The information cannot be kept confidential and the client must be informed that this will be reported to the health care staff. • This is a serious safety issue that must be reported to the staff. Using the principle of veracity, the student tells this client truthfully what must be done regarding the issue. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises A nurse decides to put a client who has psychosis in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. This is an example of: A. beneficence. B. a tort. C. a facility policy. D. justice. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises B. a tort. Beneficence: doing good for a client. Tort: a civil wrong that violates a client's civil rights. If a policy, the facility would be in violation of federal and state statute, and the nurse could be held responsible. Justice: action involving the fair and equal treatment of clients. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises A nurse is caring for a client in restraints. Which of the following statements are appropriate documentation? (SATA) A. " Client ate most of his breakfast." B. "Client was offered 8oz of water every hr." C. "Client shouted at assistive personnel." D. "Client received chlorpromazine (Thorazine) 15mg by mouth at 1000." E. "Client acted out after lunch." B, C, D: Objective data is correct, not subjective. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises B. Tell the nurse to stop discussing the behavior. The nurse should notify the nurse manager, provide in-service, and complete an incident report, but these actions are not the first to take. ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication? A. Personal space B. Posture C. Eye contact D. Intonation ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises D. Intonation Personal space, posture, and eye contact is a part of nonverbal behavior. • Intonation is the tone of one's voice and can communicate a variety of feelings. ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises D. Restating A. Takes direction. B. Enhances understanding. C. Concentrates attention to one single point. D. Restating allows the nurse to repeat the main idea expressed. ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication? A. Offering advice B. Reflecting meaning C. Listening attentively D. Giving information ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises A. Offering advice A. Advice tends to interfere with the client's ability to make personal decisions and choices. B. Reflection encourages client to make choices. C. Skill of listening is important. D. Giving information informs client of needed facts. ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises A nurse is conducting therapy with several clients and their families. Effective communication with clients and families is based on: A. discussing in-depth topics with which the client feels comfortable. B. using silence to avoid unpleasant or difficult topics. C. attending to verbal and nonverbal behaviors. D. requiring the client and family to ask for feedback. ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises C. attending to verbal and nonverbal behaviors. A. Often, very brief conversations are most effective. B. Silence is to allow the client time for reflection or to convey nonverbal support. C. Attending to verbal and nonverbal behaviors is necessary for effective communication. D. Not an effective technique. ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response? A. "I think your son is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically." ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises D. "I understand you're concerned. Let's discuss what concerns you specifically." A, B, C: Interjects nurse's opinion, causing family to withhold their thoughts and feelings. D. A therapeutic response reflects upon, and accepts, the family's feelings, and it allows the members to clarify what they are feeling. ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting. "which of the following defense mechanisms is the client using? A. Reaction formation B. Denial C. Displacement D. Sublimation ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises B. Denial A. Reaction formation: overcompensating/demonstrating the opposite behavior of what is felt. B. This is an example of denial, which is pretending the truth is not reality to manage anxiety of acknowledging what is real. C. Displacement: shifting feelings related to an object, person, or situation to another less threatening object, person, or situation. D. Sublimation: dealing with unacceptable feelings/impulses by unconsciously substituting acceptable forms of expression. ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises A nurse is obtaining informed consent for a client who has just learned she mus have a breat biopsy. The client is perspiring and pale, has a respiratory rate of 30/min, and says, "I don't quite understand what you're trying to tell me." The nurse should assess the client' s anxiety as which of the following? A. Mild B. Moderate C. Sever D. Panic ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises B. Moderate A. Mild: person's ability to understand information may actually increase. B. Moderate anxiety decreases problem-solving and may hamper one's ability to understand information. Vital signs may increase somewhat, and the person is visibly anxious. C. Severe: restlessness, decreased perception, and an inability to take direction. D. Panic: completely distracted, unable to function, and may lose touch with reality. ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client? A. Reassure the client that everything will be okay. B. Use a low-pitched voice and speak slowly. C. Ignore the client's anxiety so that she will not be embarrased. D. Demonstrate a calm manner while using simple and clear language. ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises D. Demonstrate a calm manner while using simple and clear language. A. Not appropriate. B. For severe - panic. C. Ignoring is not appropriate. D. Giving information simply and calmly will help the client grasp essential facts. ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements by the nurse is appropriate? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one." ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises C. "Losing someone close to you must be very upsetting." A. Nurse's feelings, is sympathetic and not empathetic. B. Implies judgment, not empathetic/therapeutic. C. This statement is an empathetic response that attempts to understand the client's feelings. D. Nurse's experiences. ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurse of telling him what to do just like his ex-girlfriend. C. The client reminds the nurse of a friend who died from substance overdose. D. The client becomes angry and threatens harm to himself. ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises B. The client accuses the nurse of telling him what to do just like his ex-girlfriend. A. Need to discuss boundaries. B. When a client view s the nurse as having chracteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference. C. Countertransference. D. Need for safety intervention. ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following are appropriate to include in the discussion? (SATA) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established. ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises C, D, E: Therapeutic: Goal-directed, behavioral change encouraged, and a termination date. A. Supposed to focus on the needs of the client. B. Emotional commitment = intimate/social relationship instead of therapeutic. ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions is appropriate to include in the plan of care? A. ... A nurse is working in a community mental health facility. Which of the following services are appropriate for clients to receive? (SATA) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Crisis intervention ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises A, B, C: Detoxification programs → partial hospitalization program. Crisis intervention → community treatment (ACT) program. ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises [Show More]
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