ATI RN Mental Health Asn

ATI RN Mental Health Asn Related

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A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?

  • A. Recommend that the partner place the client in a long-term care facility.
  • B. Suggest that the partner see a counselor to help him cope with his exhaustion.
  • C. Ask the partner to talk about his difficulties in caring for the client.
  • D. Tell the partner to call a family meeting to get help.
Correct Answer: C

Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.

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A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?

  • A. Sit with the client and offer simple, direct information.
  • B. Have the client attend group therapy immediately.
  • C. Explain the unit policies to the client and answer any questions he might have.
  • D. Take the client on a tour of the unit and introduce him to all the staff members on duty.
Correct Answer: A

Rationale: Clients with severe depression may have difficulty processing large amounts of information, so simple, direct communication is best.

A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

  • A. Significant change in weight
  • B. Hyperexcitability
  • C. Exaggerated response to stimuli
  • D. Attention-seeking behavior
Correct Answer: A

Rationale: The correct answer is A: Significant change in weight. In major depressive disorder (MDD), clients commonly experience appetite changes, leading to weight gain or weight loss. This is due to disturbances in their eating patterns. Weight changes can be a result of decreased interest in food or emotional eating. This is a key symptom to monitor in clients with MDD. Hyperexcitability (B), exaggerated response to stimuli (C), and attention-seeking behavior (D) are not typical findings in clients with MDD. Hyperexcitability and exaggerated response to stimuli are more often associated with conditions like anxiety disorders, while attention-seeking behavior is more commonly seen in personality disorders.

A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?

  • A. Identifying support systems.
  • B. Assisting the client in identifying coping behaviors.
  • C. Encouraging self-care.
  • D. Preventing self-directed violence.
Correct Answer: D

Rationale: Safety is the priority for clients experiencing manic episodes, as they are at risk for self-harm.

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)

  • A. Irritability
  • B. Euphoria
  • C. Chronic pain
  • D. Social withdrawal
  • E. Changes in appetite
Correct Answer: A, C, D, E

Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.

A nurse is assessing a client who has schizophrenia. The client says, "I hear voices telling me what to do." This is an example of which of the following?

  • A. Delusional disorder
  • B. Associative looseness
  • C. Hallucination
  • D. Anhedonia
Correct Answer: C

Rationale: Auditory hallucinations are common in schizophrenia, involving hearing voices that are not real.

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