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ATI Mental Health Exam 1

Total Questions : 27

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Question 1:

Order: cephalexin (Keflex) 0.5 gp.o. qid. Available: cephalexin (Keflex) 250 mg capsules. How many capsules will the nurse administer? 

Explanation

To determine the number of capsules the nurse will administer, we need to consider the dosage prescribed and the available strength of the capsules.

The prescription states: cephalexin (Keflex) 0.5 g p.o. qid (four times a day).

Given that the available strength of cephalexin capsules is 250 mg, we need to convert the prescribed dosage from grams (g) to milligrams (mg) to match the capsule strength.

1 g = 1000 mg

0.5 g = 0.5 * 1000 mg = 500 mg

Now we know that the prescribed dosage is 500 mg, and each capsule contains 250 mg.

To calculate the number of capsules needed, we divide the prescribed dosage by the strength of each capsule:

Number of capsules = Prescribed dosage / Capsule strength

Number of capsules = 500 mg / 250 mg

Number of capsules = 2

Therefore, the nurse will administer 2 capsules of cephalexin (Keflex) for each dose.


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Question 2:

A client is attending a psychiatric rehabilitation program after having been in inpatient care for the treatment of relapsing schizophrenia. When creating the plan of care, which will be the primary outcome for this client?

Explanation

When creating a plan of care for a client attending a psychiatric rehabilitation program after being in inpatient care for relapsing schizophrenia, the primary outcome should be chosen based on the client's specific needs and goals. However, let's examine each option and explain why it may or may not be the primary outcome:

The client will have an improvement in the quality of life: Improving the quality of life is an essential aspect of mental health treatment. It encompasses various areas such as social functioning, relationships, occupational functioning, and overall well-being. Enhancing the client's quality of life is a significant outcome to consider, as it focuses on promoting overall

wellness and satisfaction.

Improving the quality of life encompasses a holistic approach to recovery, considering various aspects of well-being, functioning, and personal satisfaction. It aligns with the client-centered approach and acknowledges that each individual's goals and aspirations may differ. By focusing on enhancing the overall quality of life, it allows for a comprehensive and individualized plan of care that addresses the client's unique needs.

The other choices are incorrect because:

The client will have stabilization and management of symptoms: This outcome focuses on achieving stability and effective management of symptoms related to schizophrenia. It is a crucial goal in the treatment of schizophrenia, as it aims to reduce the frequency and intensity of symptoms, leading to an improved quality of life. While this outcome is important, it may not necessarily be the primary outcome because it is often a means to achieve broader goals.

The client will return to prior level of functioning: This outcome specifically targets returning the client to their previous level of functioning before the relapse of schizophrenia. It aims to restore the client's ability to perform daily activities, engage in social interactions, and pursue their personal goals. While this outcome can be meaningful for certain individuals, it may not be applicable or feasible for all clients, especially if their prior level of functioning was significantly impaired.

The client will be adherent to the medication regimen: Adherence to medication is crucial in managing schizophrenia and preventing relapses. It ensures that the client receives the appropriate treatment and helps maintain symptom stability. While medication adherence is an important aspect of treatment, it is typically considered a treatment process goal rather than a primary outcome. It supports the achievement of other outcomes such as symptom stabilization, improved quality of life, and functional recovery.


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Question 3:

The nurse is creating a plan of care for a client experiencing a situational crisis. Which is the most measurable and obtainable goal for the client to achieve?

Explanation

When creating a plan of care for a client experiencing a situational crisis, it is important to set measurable and obtainable goals that can guide the client's progress and provide clear indicators of achievement.

Considering the options provided, the most measurable and obtainable goal for the client experiencing a situational crisis would be:

The client will resume the pre-crisis level of functioning.

This goal is measurable as it involves assessing the client's functioning before the crisis and monitoring their progress in returning to that level. It is also obtainable as it focuses on restoring the client's previous abilities and skills, rather than relying on subjective or introspective factors. By setting specific criteria to determine the pre-crisis level of functioning and regularly evaluating the client's progress, the nurse can measure the client's achievement of this goal and adjust the plan of care accordingly.

The client will resume the pre-crisis level of functioning: Resuming the pre-crisis level of functioning is a measurable and obtainable goal. It involves identifying the client's previous level of functioning and working towards returning to that state. By assessing the client's functional abilities before the crisis and monitoring progress over time, it is possible to measure and track the extent to which they have regained their previous level of functioning.

The client will discover a new sense of self-sufficiency in coping: While this goal is important for the client's long-term growth and development, it is not easily measurable or obtainable in a specific timeframe. "Discovering a new sense of self-sufficiency" is a subjective and introspective process that may require extensive self-reflection and personal growth, making it difficult to measure and set a concrete timeline for achievement.

The client will express anger regarding the crisis event: Expressing anger can be a normal and healthy part of the healing process during a crisis. However, it is not necessarily the most

measurable or obtainable goal. The expression of anger can vary greatly among individuals, and it may not be an appropriate or necessary response for everyone. Additionally, the focus of the plan of care should extend beyond anger expression and encompass a broader range of emotions and coping strategies.

The client will identify possible causes for the crisis: While understanding the possible causes of the crisis can be an important part of the recovery process, it may not be the most measurable or obtainable goal on its own. Identifying the causes of a crisis can involve complex factors that may require professional assessment and a deeper exploration of the client's history and circumstances. It is more appropriate as an ongoing process within therapy rather than a specific goal with a clear endpoint.


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Question 4:

During the assessment, the nurse asks the client to describe the client's problems. The purpose of this question is to obtain information about what?

Explanation

The purpose of asking the client to describe their problems during the assessment is to obtain information about their perception of the problem. By asking the client to describe their problems

in their own words, the nurse gains insight into how the client perceives and understands their current situation. This information helps the nurse to understand the client's subjective experience, their concerns, and their specific needs related to the problem. It allows for a more accurate assessment of the client's situation and helps in developing an individualized plan of care tailored to their unique needs.

● Personal needs: While understanding a client’s personal needs is important in providing care, it is not the primary purpose of this specific question. The nurse may ask other questions to gather information about the client’s personal needs.

● Communication skills: Assessing a client’s communication skills may be important in some cases, but it is not the primary purpose of this specific question. The nurse may use other methods to assess the client’s communication skills.

● Admitting diagnosis: The admitting diagnosis is typically determined by a physician and is based on medical tests and examinations. While the nurse may gather information that can contribute to determining the admitting diagnosis, it is not the primary purpose of this specific question.


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Question 5:

1 oz (ounce)=_____mL

Explanation

1 fluid ounce (fl oz) is equal to approximately 29.57 milliliters (ml). The conversion factor between fluid ounces and milliliters is not an exact value due to the difference between the U.S. fluid ounce and the metric milliliter. However, for most practical purposes, 1 fluid ounce is commonly rounded to 30 milliliters (ml) for simplicity.


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Question 6:

The nurse is preparing a client for a magnetic resonance imaging (MRI). Which statement(s) by the client would require the nurse to notify the health care provider to cancel the procedure? Select all that apply. (Select All that Apply.)

Explanation

The statements by the client that would require the nurse to notify the health care provider to cancel the MRI procedure are:

● “I had a pacemaker inserted a few years ago because my heart was not beating fast enough.”

● "I fell down my basement steps last year and broke my hip and had to have a hip replacement.”

● “When I was diagnosed with mitral valve prolapse, they had to replace the valve with a prosthetic valve."

These statements indicate that the client has metallic implants or devices in their body, which can be affected by the strong magnetic field of an MRI machine. This can pose a risk to the client’s safety and may interfere with the accuracy of the MRI results.

The other statements do not necessarily require the cancellation of the MRI procedure, but the nurse may need to take additional precautions or provide additional support to ensure the client’s comfort and safety during the procedure.

Here is a detailed explanation of why the other choices do not necessarily require the cancellation of the MRI procedure:

● “I have such terrible anxiety, I don’t know if I can remain still throughout the procedure.”: While anxiety can make it difficult for a client to remain still during an MRI procedure, it does not necessarily require the cancellation of the procedure. The nurse may provide additional support or medication to help the client manage their anxiety and remain still during the procedure.

● “I have diabetes mellitus type and have been taking insulin for many years.”: Having diabetes and taking insulin does not necessarily require the cancellation of an MRI procedure. The nurse may need to take additional precautions to ensure that the client’s blood sugar levels are stable during the procedure, but it does not pose a direct risk to the client’s safety or interfere with the accuracy of the MRI results.


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Question 7:

The nurse has established a therapeutic relationship with a client. Which behaviors identified will indicate that the client has entered into the identification phase of the nurse-client relationship?

Explanation

The identification phase of the nurse-client relationship is characterized by the client feeling comfortable and secure enough to open up and share their feelings, emotions, and personal experiences with the nurse. It involves establishing trust and rapport, which allows the client to feel supported and understood by the nurse. Sharing feelings and emotions indicates that the client has reached a level of comfort and trust in the therapeutic relationship, making it a key indicator of the identification phase.

The other behaviors mentioned in the options are not specifically related to the identification phase:

● The client attending therapy sessions and utilizing services provided is an important aspect of engagement and active participation in the therapeutic process. However, it does not specifically indicate the identification phase of the relationship.

● The client stating that they feel the issues have been resolved and no longer need to come suggests the termination phase of the nurse-client relationship rather than the identification phase. The termination phase occurs when the client feels they have achieved their goals and no longer require ongoing therapy.

● The client answering questions related to the plan of care is a general indicator of communication and collaboration in the therapeutic process. It does not specifically signify the identification phase but rather active involvement in the treatment plan.


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Question 8:

A baby weighs 10 pounds. How many kg does the baby weigh?

Explanation

To convert pounds (lbs) to kilograms (kg), we need to use the conversion factor: 1 pound = 0.45359237 kilograms

Now, let's calculate the weight of the baby in kilograms:

Weight in kilograms = Weight in pounds * Conversion factor

Weight in kilograms = 10 lbs * 0.45359237 kg/lb

Weight in kilograms ≈ 4.5359237 kg

Therefore, the baby weighs approximately 4.54 kilograms.


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Question 9:

The nurse is taking care of a client from a culture different from the nurse's culture. How might the nurse best provide culturally competent care?

Explanation

Culturally competent care involves understanding and respecting the diverse cultural backgrounds of clients. It requires the nurse to acquire knowledge about the client's specific culture and how it influences their healthcare preferences and practices. By taking the time to learn about the client's cultural background, the nurse can better understand their unique needs, beliefs, and values related to health and healthcare.

While continuing education and gaining knowledge about different cultures are important aspects of providing culturally competent care, it is essential to go beyond generalized expectations about cultural groups. Each individual within a culture can have unique beliefs and preferences, so it is crucial to approach each client as an individual rather than relying solely on broad cultural stereotypes.

Behaving as appropriate for the nurse's own culture may lead to misunderstandings or misinterpretations of the client's needs and preferences. It is important for the nurse to be aware of their own cultural biases and to approach care in a culturally sensitive and respectful manner.

Therefore, the best approach for the nurse to provide culturally competent care is to find out as much as possible about the client's specific cultural values, beliefs, and health practices. This

knowledge can guide the nurse in tailoring care that is respectful, responsive, and appropriate for the client's cultural background.


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Question 10:

The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?

Explanation

Boarding refers to the practice of holding patients in the emergency department (ED) for extended periods, often beyond the recommended timeframe, due to a lack of available mental health treatment options or appropriate placement. In this scenario, the nurse is notifying the manager about the presence of clients with mental health disorders who have been in the ED for more than 48 hours. This situation suggests that the hospital is likely practicing boarding for these clients.

Boarding of mental health patients in the ED can have significant negative consequences. It can contribute to overcrowding in the ED, leading to delays in care for other patients. It can also compromise the quality of care and exacerbate the distress and discomfort experienced by individuals with mental health disorders. Additionally, it is not an optimal environment for mental health treatment and recovery.

By discussing the issue of boarding with the manager, the nurse is addressing the need for timely and appropriate placement for clients with mental health disorders. This conversation may involve exploring solutions such as improving access to mental health services, establishing dedicated mental health units or crisis stabilization centers, and collaborating with community resources to ensure a smooth transition of care for these clients.

The other options mentioned are not directly related to the issue of clients with mental health disorders being present in the ED for over 48 hours:

● Temporary detaining orders for clients: This refers to legal mechanisms that allow for the temporary detention of individuals with mental health disorders who may pose a risk to themselves or others. While it may be related to the care of these clients, it does not address the issue of prolonged stays in the ED.

● The revolving door for clients: This concept refers to the frequent readmission or return of clients to the ED or hospital due to ongoing mental health issues. While it is a concern in mental health care, it does not specifically pertain to the issue of clients remaining in the ED for an extended period.

● The cost of holding clients in the ED for over 48 hours: While the cost implications of extended stays in the ED are relevant, the primary concern in this scenario is the quality of care, appropriate placement, and the impact on both the clients and the ED's functioning.


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Question 11:

A client has been started on antidepressants. Which interdisciplinary team member is most responsible for monitoring effectiveness and side effects of this new medication?

Explanation

While all members of the interdisciplinary team play important roles in the care of a client started on antidepressant medication, the psychiatric nurse typically takes a leading role in monitoring the medication's effectiveness and side effects.

1. Pharmacist: The pharmacist plays a crucial role in ensuring the safe and accurate dispensing of medications. They provide important information about the medication, its dosing, and potential drug interactions. However, they may not be directly involved in monitoring the client's response to the medication or assessing for specific side effects.

2. Psychiatrist: The psychiatrist is responsible for prescribing the antidepressant medication and determining the appropriate treatment plan for the client. While they may periodically review the client's progress and adjust the medication as needed, their role may focus more on the overall management of the client's mental health condition rather than continuous monitoring of the medication's effectiveness and side effects.

3. Psychologist: The psychologist typically focuses on providing therapy and counseling services to the client. While they may have knowledge about the effects of antidepressant medication, their primary role is not to monitor its effectiveness or side effects.

4. Psychiatric nurse: The psychiatric nurse is often at the forefront of medication monitoring and management. They closely observe the client for changes in symptoms, assess the client's response to the antidepressant medication, and monitor for any potential side effects or adverse reactions. The psychiatric nurse may collaborate with the psychiatrist and other team members to adjust the medication regimen and provide ongoing support and education to the client about their medication.


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Question 12:

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

Explanation

An evolving consumer household, also known as a supported or assisted living arrangement, is designed to provide individuals with a greater level of independence and autonomy compared to a traditional group home setting. The emphasis is on empowering clients to develop and enhance their skills and abilities to live more independently.

By transitioning to an evolving consumer household, the ultimate goal is for the client to be able to fulfill their daily responsibilities without constant supervision. This includes activities such as managing their personal care, household tasks, budgeting, meal preparation, and other essential activities of daily living. The aim is to promote self-sufficiency and a sense of personal agency, enabling the client to become more self-reliant and self-directed in their daily life.

While meeting with a therapist on a weekly basis may be a component of the client's overall treatment plan, it is not the primary goal of transitioning to an evolving consumer household. The focus is more on developing independent living skills rather than solely on therapeutic interventions.

Similarly, although emotional support from paid staff may be available in the evolving consumer household, the goal is not to solely rely on increased emotional support but rather to gradually reduce the need for constant support and supervision.

Resolving crises within a shorter time period is an important aspect of care in any setting, but it is not specifically tied to the transition from a group home to an evolving consumer household. Crisis management skills and strategies can be addressed in various settings to ensure the client's well-being and safety.


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Question 13:

A nurse is assisting a client who is working on the technique of systematic desensitization. Which statement made by the nurse best uses the principle of technique?

Explanation

Systematic desensitization is a therapeutic technique used to treat phobias and anxiety disorders. It involves gradually exposing the client to the feared situation or object while practicing relaxation techniques to reduce anxiety. The goal is to help the client develop a new, more positive response to the feared stimulus.

The statement "What is the worst that will happen if you confront this fear?" aligns with the principle of systematic desensitization by encouraging the client to explore their fears and confront the worst-case scenario associated with their anxiety. This technique is known as "fear confrontation." By examining the potential consequences of the feared situation, the client can challenge their negative beliefs and assumptions, leading to a reduction in anxiety and increased confidence in facing the fear.

The other statements also demonstrate supportive and empathetic communication but do not specifically address the principles of systematic desensitization:

"I can see you are anxious. Let's stop for a minute." acknowledges the client's anxiety but does not directly address the technique of systematic desensitization.

"Use the deep breathing techniques we practiced yesterday." suggests the use of relaxation techniques, which are a key component of systematic desensitization, but does not specifically focus on the principle of fear confrontation.

"Tell me how you are feeling right now." encourages the client to express their emotions but does not directly address the technique or principles of systematic desensitization.

Therefore, the statement that best uses the principle of the technique of systematic desensitization is "What is the worst that will happen if you confront this fear?" as it prompts the client to explore their fears and challenge their negative beliefs.


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Question 14:

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

Explanation

When discussing culturally competent care at a nursing staff inservice, the nurse should include information about the importance of focusing on clients’ cultures when providing care. Culture plays a significant role in determining when a client will seek medical care and how they will respond to treatment. Nonverbal communication is important in many cultures and can provide valuable information about a client’s needs and preferences. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices, rather than expecting clients to adapt to the care provided.

● “Culture plays no role in determining when a client will seek medical care.” This statement is incorrect because culture can play a significant role in determining when and how a client seeks medical care. Cultural beliefs and practices can influence a client’s understanding of health and illness, their attitudes towards healthcare providers, and their willingness to seek and adhere to treatment.

● “Nonverbal communication is important in few cultures.” This statement is incorrect because nonverbal communication is important in many cultures. Nonverbal cues such as body language, facial expressions, and gestures can convey important information about a client’s emotions, needs, and preferences. Understanding and responding to nonverbal communication can help nurses provide culturally competent care.

● “Nurses should expect clients to adapt to the care provided regardless of culture.” This statement is incorrect because it is not culturally competent to expect clients to adapt to the care provided without considering their cultural beliefs and practices. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices. This may involve adapting the care provided to meet the unique needs of each client.


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Question 15:

A client unable to work due to relapsing schizophrenia is receiving Social Security Benefits. Which benefit will this provide to the client experiencing serious mental illness?

Explanation

Social Security benefits can provide financial support to individuals who are unable to work due to a serious mental illness such as relapsing schizophrenia. This financial support can help the client maintain some level of independence by providing them with a source of income. However, it is important to note that the amount of benefits received may not be sufficient to cover all of the client’s expenses, including the cost of medication and other bills. Social Security benefits do not guarantee access to psychiatric services or dictate the type of treatment that a client can receive.

The other choices are incorrect for the following reasons:

● “The client will have the ability to obtain psychiatric service regardless of setting.” This statement is incorrect because receiving Social Security benefits does not guarantee access to psychiatric services. Access to care can depend on a variety of factors, including the availability of services in the client’s area and their ability to pay for care.

● “The client will be able to pay all of their bills as well as purchase medication.” This statement is incorrect because the amount of Social Security benefits received may not be sufficient to cover all of the client’s expenses. The cost of living and healthcare can vary widely, and the amount of benefits received may not be enough to cover all of the client’s bills and medication costs.

● “The client will have the option to only obtain inpatient treatment.” This statement is incorrect because receiving Social Security benefits does not dictate the type of treatment that a client can receive. The appropriate treatment for a client with relapsing schizophrenia will depend on their individual needs and circumstances. Inpatient treatment may be appropriate in some cases, but other forms of treatment, such as outpatient therapy or medication management, may also be effective.


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Question 16:

he nurse observes the client experiencing a panic attack in the day room in the behavioral health unit. Which is the priority action by the nurse?

Explanation

During a panic attack, the client may experience intense fear and anxiety, accompanied by physical symptoms such as rapid heart rate, shortness of breath, and trembling. The most critical action the nurse should take is to stay with the client and provide support. By remaining present, the nurse can help the client feel safe and reassured, while also monitoring their condition for any signs of worsening distress or the need for further intervention. Maintaining a safe environment is also crucial to prevent any harm to the client or others. Once the immediate crisis is managed and the client starts to calm down, the nurse can then proceed with other interventions, such as education on coping strategies or engaging in activities to redirect their focus. However, in this situation, the priority is to provide immediate support and ensure the client's safety.

The following are incorrect because:

Educate the client in ways to prevent a future panic attack: While education on preventing future panic attacks is important, it is not the priority action during an ongoing panic attack. The client is currently in distress and needs immediate support and assistance in managing the panic attack. Education can be provided at a later time when the client is calmer and more receptive to learning.

Take the client for a walk around the unit: Taking the client for a walk may be a beneficial intervention to help reduce anxiety and promote relaxation in some situations. However, during an active panic attack, the client may be experiencing significant distress and physical symptoms that can make movement difficult or exacerbate their symptoms. It is essential to prioritize the client's immediate needs and provide a supportive environment before considering other activities or interventions.

Redirect the client to an activity or task: Redirecting the client to an activity or task may be helpful in some situations to distract them from their anxiety. However, during a panic attack, the client may find it challenging to engage in activities or focus on tasks due to their heightened state of anxiety. Redirecting their attention without addressing their immediate distress may not be as effective or appropriate as providing support and maintaining a safe environment.


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Question 17:

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)

Explanation

The nurse should include the following components when performing a mental status examination (MSE) on a client with a new diagnosis of dementia:

● Grooming: Assessing the client's grooming and personal hygiene can provide insights into their ability to care for themselves and maintain basic activities of daily living.

● Long-term memory: Evaluating the client's long-term memory can help identify any deficits or impairments in their ability to recall past events, experiences, or personal information. This is particularly relevant in dementia, as it often affects memory function.

● Support systems: Assessing the client's support systems, such as family members, friends, or caregivers, is essential in understanding the resources available to the client and the level of assistance they may require in managing their dementia.

● Affect: Evaluating the client's affect refers to observing their emotional expression and responsiveness during the assessment. In dementia, changes in affect can occur, such as a flat affect or inappropriate emotional responses.

The component that should not be included in the MSE for a client with dementia is:

● Presence of pain: While pain assessment is an important aspect of caring for individuals with various health conditions, including dementia, it is not a specific component of the mental status examination. Pain assessment is typically addressed separately and should be conducted when necessary or based on the client's specific complaints or indications of pain.


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Question 18:

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Explanation

Assessing the carotid pulse simultaneously on both sides of the neck can potentially lead to excessive pressure on the carotid arteries, which supply blood to the brain. This pressure can compromise blood flow to the brain and result in adverse effects, such as decreased blood supply and oxygenation to the brain tissues.

In clinical practice, it is generally recommended to assess the carotid pulse unilaterally, meaning one side at a time, to ensure adequate blood flow to the brain is maintained during the assessment. This allows for a proper evaluation of the pulse without interfering with the circulatory system.

The other choice are incorrect:

Femoral: Assessing the femoral pulse bilaterally at the same time is generally considered safe. The femoral artery is located in the groin area and provides blood supply to the lower

extremities. Bilateral assessment allows for comparison of pulses and evaluation of circulation in both legs.

Popliteal: The popliteal pulse is located behind the knee. Similar to the femoral pulse, assessing the popliteal pulse bilaterally at the same time is typically safe. It allows for comparison between both legs and evaluation of lower limb circulation.

Brachial: The brachial pulse is located in the upper arm and is commonly used for blood pressure measurement in clinical settings. Assessing the brachial pulse bilaterally at the same time is generally considered safe and is routinely done during blood pressure assessment.


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Question 19:

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?

Explanation

When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.

the other choices are incorrect:

1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.

2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.

3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.


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Question 20:

Order, digoxin (Lanoxin) 0.25 mg IM daily. Available digoxin (Lanoxin) 0.5 mg/2 mL How many mL will the nurse administer? 

Explanation

To calculate the amount of mL the nurse should administer, we can use a proportion based on the available concentration of digoxin (Lanoxin) and the prescribed dose.

The available concentration is 0.5 mg/2 mL, which means there are 0.5 mg of digoxin in 2 mL of solution.

The prescribed dose is 0.25 mg.

Now we can set up the proportion:

0.5 mg / 2 mL = 0.25 mg / x mL

Cross-multiplying, we have:

0.5 mg * x mL = 2 mL * 0.25 mg

0.5x = 0.5

Dividing both sides by 0.5, we get:

x = 0.5 / 0.5

x = 1

Therefore, the nurse should administer 1 mL of digoxin (Lanoxin) to deliver a dose of 0.25 mg.


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Question 21:

The nurse is performing an admission assessment for a client admitted to the behavioral health unit. Which social/cultural category will the nurse document that may be contributing to the client's degree of mental illness? Select all that apply. (Select All that Apply.)

Explanation

The client attributes life's problems to being without family support: Lack of family support can significantly impact an individual's mental health and well-being. It can lead to feelings of isolation, loneliness, and a lack of emotional support, potentially contributing to the development or exacerbation of mental illness.

The client is unable to find work and does not have enough money for housing: Financial instability, unemployment, and inadequate housing are social determinants of mental health. These factors can contribute to stress, anxiety, and a sense of hopelessness, which may impact the client's mental well-being.

The client states that they are discriminated against due to their country of origin: Experiencing discrimination based on one's country of origin can lead to feelings of marginalization, social exclusion, and psychological distress. Discrimination is a social factor that can contribute to the development of mental illness or exacerbate existing mental health conditions.

The client reports not belonging anywhere and is without family support: Feeling a lack of belonging or a sense of disconnectedness can have a negative impact on mental health. It can contribute to feelings of isolation, low self-esteem, and depression. Additionally, lacking family support further compounds the client's sense of not belonging, potentially affecting their mental well-being.

Incorrect:

The client reports being unable to find anything meaningful within their life: While this statement suggests a lack of purpose or fulfillment in the client's life, it does not specifically address social or cultural factors that could contribute to their mental illness. It may be important to explore further during the assessment to identify underlying issues, but it does not fall under the social/cultural category.


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Question 22:

Lasix 50 mg IV. The available vial contains 80mg/2ml. What is the dose in ml?

Explanation

To calculate the dose of Lasix (furosemide) in milliliters (ml), we can set up a proportion using the available concentration and the prescribed dose.

The available concentration is 80 mg/2 ml, which means there are 80 mg of Lasix in 2 ml of solution.

The prescribed dose is 50 mg.

Setting up the proportion:

80 mg / 2 ml = 50 mg / x ml

Cross-multiplying:

80 mg * x ml = 2 ml * 50 mg

80x = 100

Dividing both sides by 80:

x = 100 / 80

x = 1.25

Therefore, the dose of Lasix 50 mg IV would be approximately 1.25 ml.


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Question 23:

Which is true regarding mental health and mental illness?

Explanation

This definition highlights the importance of positive relationships, effective coping strategies, a positive self-concept, and emotional stability in determining mental health.

The others are incorrect:

1. It is not easy to determine if a person is mentally healthy or mentally ill: Assessing mental health and diagnosing mental illness requires a comprehensive evaluation by trained professionals. Mental health is a complex and multifaceted aspect of overall well-being that involves various factors, and determining someone's mental health status is not a simple or straightforward process.

2. Persons who engage in fantasies are mentally ill: Engaging in fantasies is not necessarily indicative of mental illness. Fantasies can be a normal part of human imagination and creativity. However, the context and intensity of fantasies, along with other psychological and behavioral indicators, would need to be considered in a comprehensive assessment to determine if there are any underlying mental health concerns.

3. Behavior that may be viewed as acceptable in one culture is always unacceptable in other cultures: Cultural norms and values vary across societies, and what may be deemed acceptable or unacceptable behavior can differ significantly. There is no

universal standard for judging the acceptability of behavior across all cultures. Cultural relativism recognizes that behaviors and norms should be understood within their cultural context.


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Question 24:

The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?

Explanation

Boarding refers to the practice of holding patients, including those with mental health disorders, in the emergency department (ED) for extended periods due to the unavailability of appropriate psychiatric or mental health treatment facilities. This situation often occurs when there is a lack of inpatient psychiatric beds or insufficient community-based mental health resources.

When the nurse notifies the manager about clients with mental health disorders still present in the ED for over 48 hours, they are likely raising concerns about the practice of boarding. The nurse is highlighting the issue of keeping individuals with mental health disorders in an inappropriate setting for an extended duration, which can have negative implications for both the clients and the ED.

The other options are not directly related to the phenomenon of clients with mental health disorders staying in the ED for an extended period:

1. Temporary detaining orders for clients: Temporary detaining orders refer to legal provisions that allow for the involuntary detention of individuals who are at risk to themselves or others due to mental health concerns. While this may be relevant in certain situations, it does not address the broader issue of clients staying in the ED beyond 48 hours.

2. The revolving door for clients: The revolving door phenomenon refers to individuals repeatedly seeking care in the ED due to ongoing or recurrent health issues. While this may be a concern in the context of mental health, it does not specifically address the issue of clients with mental health disorders staying in the ED for over 48 hours.

3. The cost of holding clients in the ED for over 48 hours: While the cost of providing care and resources to clients staying in the ED for an extended period is a valid consideration, it does not encompass the broader issue of the appropriateness of this practice for clients with mental health disorders.


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Question 25:

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

Explanation

The transition from a group home to an evolving consumer household typically involves promoting independence and empowering the client to become more self-sufficient. The ultimate goal is to enable the client to fulfill their daily responsibilities without the need for constant supervision or assistance.

The others are incorrect:

While meeting with a therapist on a weekly basis may be part of the client's overall mental health support, it is not the specific goal of transitioning to an evolving consumer household.

Using the increased emotional support of paid staff may be a temporary measure during the transition period, but the long-term goal is for the client to become self-reliant and less dependent on constant emotional support.

Resolving crises within a shorter time period is a desirable outcome for any mental health support system, but it does not directly relate to the specific goal of fulfilling daily responsibilities without supervision.


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