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. 4) A nurse is caring for a pt who has anorexia nervosia. Which of the following criteria requires hospitalization? Weight loss 10% of total body weight in 3 months Criteria for hospitalization is weight loss over 30% of total body weight in 6 months. Potassium 3.8 mEq/L A potassium level of 3.8 mEq/L is within the expected reference range. A potassium level less than 3 mEq/L is criteria for hospitalization. Temperature 35.6° C (96.1° F) Severe hypothermia, a temperature lower than 36° C (96.8° F) due to loss of subcutaneous tissue or dehydration, requires hospitalization. Heart rate 54/min Criteria for hospitalization is a heart rate less than 40/min. 5) A nurse in a mental health clinic is caring for a pt who has bipolar disorder and reports that she stopped taking Lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the pt to stop taking the med? Sore throat A sore throat is not an expected adverse effect of lithium. Photophobia Photophobia is not an expected adverse effect of lithium. Hand tremors Fine hand tremors are an expected adverse effect of lithium and can interfere with the client's ADLs, causing the client to stop taking the medication. Constipation Diarrhea is an early manifestation of lithium toxicity. 6) A nurse in an ER is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter’s diagnosis? "She works so hard at ballet. Will she still be able to perform?" This statement provides little insight into the client's current psychological condition and indicates that the mother might be in denial. "She won't let me take the trash from her room. I'm concerned about what she has in there." The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statement indicates awareness of her daughter's behavior. "She told me she was tired, so I did her chores for her today." This statement by the mother indicates that she is responding to her daughter's eating disorder with enabling behavior. "She is happier with her appearance now that she's lost some weight." This statement suggests that the mother is identifying positive effects of the eating disorder rather than understanding the negative health effects it has on her daughter. 7) A nurse is caring for a pt who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following pt behaviors indicates effectiveness of the therapy? Controls anger outbursts to avoid being placed in seclusion Changing behavior to avoid punishment is not an optimal goal of operant conditioning therapy. No longer exhibits a fear of social or public situations There is no evidence that this client has a social phobia. Phobias are usually treated with desensitization therapy. Refrains from manipulating others to earn dining-room privileges The goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. Refraining from manipulative behavior is a desired response. Imitates the therapist's use of a relaxation technique Imitating behavior is modeling and does not demonstrate the desired outcome of operant conditioning. 8) A nurse is admitting a pt who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? Encourage the client to drink 125 mL of fluid each hour while awake. [Show Less]