ATI Mental Health Final Quiz (aka Quiz 3)

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• "Let's ignore the voices and talk about something else." The nurse should ask the client directly about what the voices are saying to determine if there is a safety risk. The nurse should also avo... id validating that the voices are real, which promotes the client’s beliefs about the delusion. • "That must be very frightening." The nurse should respond to the client’s delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse- client relationship. • "Why do you think the TV is a two-way radio?" The nurse should avoid asking the client a "why" question, which promotes a defensive client response. • A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? • Practicing problem-solving skills The nurse should encourage the client to practice problem-solving skills during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. • Understanding of medication regimen The nurse should ensure that the client understands the medication regimen during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. • Identifying indications of relapse The nurse should teach the client to recognize indications of relapse during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. • Maintaining adequate hydration The nurse should identify that the priority goal is to prevent physical exhaustion, maintain health, and meet nutritional and rest needs during the acute phase of the client’s manic episode. The nurse should consider aslow’s hierarchy of needs, which includes five levels of priority when planning care for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. hen applying aslow’s hierarchy of needs priority-setting framework the nurse should review physiological needs first. The nurse should then address the client’s needs by following the remaining four hierarchical levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of aslow’s hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling [Show More]

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