ATI Mental Health Online Practice

ATI Mental Health Online Practice

2019 A with NGN

• A nurse is assessing a client who has schizophrenia. Which of the fol-

lowing findings should the nurse document as a negative symptom of this disorder?

• Delusions
• Neologisms
• Anhedonia

D. Echopraxia:

• Anhedonia

Rationale: Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative include flat affect, anergia (lack of en- ergy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.

• A nurse is caring for an older adult client who has dementia and has

wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?

• Move the client to a room near the nurse's station
• Limit visitors until the client is oriented to the environment
• Tell the client that their partner is deceased

D. Talk with the client about activities they enjoyed with their partner:

• Talk with the client about activities they enjoyed with their partner

Rationale: Talking about positive experiences can help distract the client from their disorientation

• A nurse is caring for a client whose child has a terminal illness. The client

requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

• "It will be better for you to keep busy to avoid thinking about your child's

death."

• "You will complete the grieving process about a year after your child's

death."

• "The grief process will start once your child actually dies." 1 / 3

D. "It is not uncommon to feel angry toward yourself or others.":

• "it is not uncommon to feel angry toward yourself or others."

Rationale: Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.

• A nurse is teaching a client who has a depressive disorder about fluox-

etine. Which of the following information should the nurse include in the teaching?

• "You might notice an increase in saliva while taking this medication."

• "You might experience difficulties with sexual functioning while taking

this medication."

• "You should expect an improvement in symptoms of depression in 3 to 4

days."

• "You may notice a temporary ringing in the ears when starting this med-

ication.":

• "You might experience difficulties with sexual functioning while taking this

medication." Rationale: Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual dysfunction occurs.

• A nurse is admitting a client who has schizophrenia to an acute care

setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?

• Clang association
• Word salad
• Neologism

D. Echolalia:

• Clang association

Rationale: The nurse should document that they client's speech uses clang asso-

ciations, which often rhyme or contain a string of words that can have a similar sound.

• A nurse is obtaining a mental health history from an older adult client.

Which of the following actions should the nurse plan to take?

• Raise the pitch of the voice when speaking to the client
• Begin the interview by explaining the plan of care
• Interview the client in a private setting

D. Ask the client to complete a detailed questionnaire:

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• Interview the client in a private setting

Rationale: The nurse should interview clients in a private place when asking

questions regarding client health.

• A community health nurse is planning an education program about de-

pressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

• Male gender
• Hyperthyroidism
• Substance use disorder

D. Being married:

• Substance use disorder

Rationale: The nurse should identify that clients who have a substance use disorder are at an increased risk for the development of depressive disorders.

• A nurse is planning discharge for a client who has bipolar disorder and has

a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication.

• "I should eat a regular diet with normal amounts of salt and fluids."
• "I should discontinue the lithium when I begin to feel better."
• "I need to be careful to avoid becoming addicted to the lithium."

D. "I can skip a dose of medication if my stomach is upset.":

• "I should eat a regular diet with normal amounts of salt and fluids."

Rationale: The nurse should identify that this statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodim levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity.

• A nurse is caring for a client who has a history of substance use disorder

and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the med- ication and becomes physically aggressive. Which of the following actions should the nurse take?

• Do not administer the lorazepam
• Request a prescription
• Request that another nurse attempt to administer the lorazepam

D. Place the lorazepam in the client's food:

• Do not administer the lorazepam Rationale: Clients who are in a facility due to

an involuntary admission retain the right to refuse treatment. Therefore, the nurse should hold the medication and document the client's refusal.

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