ATI RN Mental Health and Psychiatric NursingTestbank with answers & Rationale(Substance Abuse and Abuse)
1. The nurse is caring for a severely depressed
... [Show More] client who has just been admitted to the in-client
psychiatric unit. Which of the following is a priority of care?
A. Nutrition
B. Elimination
C. Rest
D. Safety
Correct Answer: D. Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of theplan. Identify the level of suicide precautions needed. If there is a high-risk, does a hospitalizationrequire it? Or if there is a low risk, will the client be safe to go home with supervision froma family
member or a friend? A client with a high-risk will require constant supervision and a safe environment. Option A: Encourage small, high-calorie, and high-protein snacks and fluids frequently throughout
the day and evening if weight loss is noted. Minimize weight loss, constipation, and dehydration. Encourage eating with others. Increases socialization, decreases focus on the food. Weight theclient
weekly and observe the eating patterns of the client. Give the information needed for revising theintervention. Option B: Monitor intake and output, especially bowel movements. Most of the depressed clients
are constipated. If this problem is not addressed, it can lead to fecal impaction. Encourage theintake of nonalcoholic and non-caffeinated fluids, 6 to 8 glasses a day. Fluids can help prevent
constipation. Offer fiber-rich foods and periods of exercise. Roughage and exercise stimulate
peristalsis and help evacuation of fecal material. Option C: Provide rest periods after activities. Fatigue can intensify feelings of depression. Encourage relaxation measures in the evening (e.g., drinking warm milk, back rub, or tepid bath). These measures induce sleep and relaxation. Encourage the client to get up and dress and tostayout of bed during the day. Minimizing sleep during the day increases the likelihood of sleep at night. Reduce environmental and physical stimulants in the evening; Provide decaffeinated coffee, soft
music, soft lights, and quiet activities. 2. Which situation would Nurse Sally identify as placing a client at high risk for caregiver abuse?A. Antonia, an adult child, quits her job to move in and care for a parent with severedementia. B. Mr. Wright, an elderly man with severe heart disease, resides in a personal carehome and is frequently visited by his adult child.
[email protected]
C. Mrs. Hale, an elderly parent with limited mobility, lives alone and receives helpfromseveral adult children. D. Antoinette cares for her husband who is in early stages of Alzheimer's disease andhas a network of available support persons. [Show Less]