ATI MENTAL HEALTH 2016 PRACTICE A 1) A nurse is assessing a pt who has bulimia nervosa. The nurse should expect which of the following findings?
... [Show More] Amenorrhea A client who has anorexia nervosa is more li kely to have amenorrhea resulting from low body weight. Lanugo A client who has anorexia nervosa is more likely to have lanugo resulting from extreme malnutrition. Cold extremities A client who has anorexia nervosa is more likely to have cold extremities from extreme malnutrition. Tooth erosion A client who has bulimia nervosa is likely to have dental carries and tooth erosion caused by frequent exposure to gastric acid from vomiting. 2) A nurse in a mental health unit observes a pt who has acute mania hit another pt. Which of the following actions should the nurse take first? Call the provider to obtain an immediate prescription for restraint. Calling the provider for an immediate prescription for restraint is an appropriate action. However, this is not the first action the nurse should take. Prepare to administer benzodiazepine IM. An IM injection of a benzodiazepine might be indicated for this client. However, this is not the first action the nurse should take. Call for a team of staff members to help with the situation. The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others. Check the client who has was hit for injuries. Once the nurse and other clients are safe, the nurse should assess the client who was hit for injuries to determine if medical intervention is needed. However, this is not the first action the nurse should take. 3) A nurse is performing a cognitive assessment to distinguish delirium from dementia in a pt whose family reports episodes of confusion. Which of the following assessment findings supports the nurse’s suspicion of delirium? Slow onset Delirium has an acute onset. Dementia is a slow, progressive decline. Aphasia Aphasia is a manifestation of dementia. Confabulation Confabulation is a manifestation of dementia. Easily distracted Extreme distractibility is a hallmark manifestation of delirium. [Show Less]