Ati remediation exam 3 (mental & med surg)
Total Questions : 78
Showing 25 questions, Sign in for moreA nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
Explanation
Rationale:
A. Placing a client with active tuberculosis in a room with another client increases the risk of airborne transmission of the infection, which is inappropriate for infection control.
B. A room with air exhaust directly to the outdoor environment is ideal for a client with active tuberculosis because it provides negative pressure, helping to contain and prevent the spread of the infectious airborne particles.
C. The ICU is typically reserved for critically ill patients requiring intensive monitoring and care, and it may not provide the necessary infection control measures for TB.
D. A room near the nurses' station would not ensure the negative pressure ventilation needed to prevent airborne transmission of tuberculosis.
A nurse is discussing strategies to develop nurse-client therapeutic relationships with a newly licensed nurse. Which statement by the nurse accurately describes strategies for building a therapeutic relationship?
Explanation
Rationale:
A. Listening attentively and summarizing the client's comments are key techniques in developing a therapeutic relationship, as they demonstrate understanding, empathy, and engagement.
B. Asking questions that elicit only one-word responses limits the depth of conversation and does not encourage clients to express their feelings or concerns.
C. Avoiding direct questions about suicidal behaviors or thoughts is not appropriate, as addressing these concerns directly is crucial in assessing and ensuring client safety.
D. Allowing the client’s family to attend all group therapies may not always be appropriate, as it could impede the client’s ability to express themselves freely and might not be suitable for all therapeutic settings.
A nurse working in a community health center is speaking with a client who has a serious mental illness. The client states that they are unable to find employment and they do not understand why. Which of the following questions should the nurse ask? (Select all that apply.)
Explanation
Rationale:
A. Asking about salary range is not directly relevant to the client’s mental health condition and would not help in understanding the barriers to employment.
B. Inquiring if the client has served time in prison may reveal a history that could impact their employability, as some employers may have restrictions on hiring individuals with criminal records.
C. Asking about the type of vehicle the client drives is not directly related to the client’s mental health or barriers to employment, and it would not provide insight into why the client is struggling to find work.
D. Asking about drug use is pertinent as substance abuse can interfere with employment opportunities and overall functioning.
E. Knowing whether the client is taking antipsychotic medication is important because adherence to treatment can significantly affect the client’s ability to function in a work environment.
A nurse is caring for a client who has schizophrenia with an exacerbation of hallucinations. The client states, "I do not understand why the hallucinations have come back." The nurse should explain that which of the following is the reason for the exacerbation of hallucinations?
Explanation
Rationale:
A. Boundaries refer to maintaining professional limits in the nurse-client relationship, which is not directly related to the cause of hallucination exacerbation.
B. Relapse is the return of symptoms after a period of improvement, which is a common explanation for the recurrence of hallucinations in a client with schizophrenia.
C. The SE model (Social Ecological Model) is a framework for understanding the various levels of influence on health behaviors and is not a direct cause of hallucinations.
D. Stigma refers to the negative attitudes and beliefs about mental illness, which can affect a client’s self-perception but is not a direct cause of symptom exacerbation.
A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. Which of the following client statements indicates that the client is experiencing traumatic grief?
Explanation
Rationale:
A. This statement may indicate prolonged grief or depression but does not specifically point to the guilt or distress seen in traumatic grief.
B. This describes a physiological response to flashbacks, which is more indicative of post-traumatic stress disorder (PTSD) rather than traumatic grief.
C. This statement reflects emotional suppression, which can be common in military culture but does not directly indicate traumatic grief.
D. Expressing survivor's guilt, as in feeling that they should have died instead of their friend, is a hallmark of traumatic grief and indicates the client is struggling with the loss in a deeply distressing way.
A nurse is caring for a client who has schizophrenia and diabetes mellitus. The nurse is reviewing a list of the client's prescribed medications and has questions about interactions. To which of the following members of the interprofessional team should the nurse direct their questions?
Explanation
Rationale:
A. The psychiatric pharmacist specializes in the management of medications for clients with mental health conditions and would be the most knowledgeable about potential interactions between psychiatric and diabetes medications.
B. A laboratory technician focuses on conducting lab tests and would not be the appropriate team member to consult regarding medication interactions.
C. While the primary provider oversees the overall care of the client, the psychiatric pharmacist is specifically trained to handle questions about medication interactions, making them the best resource in this scenario.
D. A psychologist typically addresses therapeutic interventions and behavioral therapies, not medication management, making them less suited to answer questions about drug interactions.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Explanation
Rationale:
A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.
B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.
C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.
D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.
A nurse is teaching a newly licensed nurse about the importance of therapeutic communication. Which of the following statements should the nurse include in the teaching?
Explanation
Rationale:
A. This statement undermines the importance of therapeutic communication, which is essential in building trust and understanding with clients.
B. Therapeutic communication is indeed a fundamental part of mental health nursing and plays a crucial role in establishing a therapeutic relationship that supports the client's emotional and psychological well-being.
C. Therapeutic communication is vital in nurse-client interactions and is integral to effective mental health care, not just nurse-to-nurse communication.
D. Therapeutic communication in healthcare requires specific skills and approaches that differ from everyday conversation, emphasizing the need for sensitivity, empathy, and active listening.
A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa?
Explanation
Rationale:
A. Spending time searching for new recipes does not necessarily indicate anorexia nervosa and might be associated with interest in food without consumption.
B. Reporting high energy levels is not characteristic of anorexia nervosa, where clients often suffer from fatigue due to inadequate nutrition.
C. Enjoying wearing form-fitting clothes is more indicative of a positive body image, which is not typical of those with anorexia nervosa.
D. The statement "I know I am skinny" reflects an awareness of low body weight, which, in the context of anorexia nervosa, might indicate a distorted body image and an unhealthy focus on being underweight.
A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include? (Select All that Apply.)
Explanation
Rationale:
A. The Harvard Implicit Association Test (IAT) measures implicit biases and is not used specifically for assessing suicide risk.
B. The PHQ-9 (Patient Health Questionnaire-9) is a validated tool for screening, diagnosing, monitoring, and measuring the severity of depression, which is closely related to suicide risk.
C. The Altman Self-Rating Mania Scale is used to assess the severity of manic symptoms in clients with bipolar disorder, not for suicide risk assessment.
D. The SAD PERSONS scale is a tool specifically designed to assess suicide risk based on key risk factors.
E. The SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) is a comprehensive framework for assessing suicide risk, making it an appropriate tool to include in suicide risk assessments.
A nurse is preparing to care for a client who is experiencing complicated grief. Which of the following actions demonstrates grief-informed care?
Explanation
Rationale:
A. Contacting the provider for directions may be necessary in some cases, but it does not directly demonstrate grief-informed care, which involves understanding and addressing the emotional needs of the grieving client.
B. Supporting the client's privacy is important, but avoiding discussions about the loss may prevent the client from processing their grief, which is not aligned with grief-informed care.
C. Standing while speaking and keeping the door open can make the client feel uncomfortable or unsupported during a vulnerable time. Grief-informed care emphasizes creating a supportive and empathetic environment.
D. Acknowledging and recognizing that the client has experienced a loss is a key component of grief-informed care. It validates the client's feelings and opens the door for further support and therapeutic interventions.
A staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action?
Explanation
Rationale:
A. Reporting the incident to other RNs on the shift does not ensure that the appropriate actions will be taken to address the issue.
B. Agreeing not to report the incident in exchange for the coworker seeking treatment is unethical and does not follow the correct reporting protocol.
C. Reporting the incident to the appropriate person in the chain of communication, such as a supervisor or nurse manager, is the correct course of action. This ensures that the situation is handled according to hospital policy and legal requirements, protecting patient safety and addressing the coworker's substance use disorder.
D. Agreeing not to report the incident if the coworker promises to report themselves is also unethical and fails to meet professional responsibilities.
A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home? (Select All that Apply.)
Explanation
Rationale:
A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.
B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.
C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.
D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.
E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.
A nurse is caring for a client who has illness anxiety disorder. Which of the following medications should the nurse expect the provider to prescribe?
Explanation
Rationale:
A. Escitalopram is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for anxiety disorders, including illness anxiety disorder. It helps to manage the anxiety symptoms associated with the condition.
B. Haloperidol is an antipsychotic medication used to treat schizophrenia and other psychotic disorders but is not typically prescribed for illness anxiety disorder.
C. Olanzapine is an antipsychotic medication used to treat schizophrenia and bipolar disorder but is not generally used for illness anxiety disorder.
D. Carbamazepine is an anticonvulsant and mood stabilizer used to treat bipolar disorder and epilepsy, but it is not indicated for illness anxiety disorder.
A nurse asks a client if they prefer to attend the morning or afternoon group therapy session. The nurse should identify that this as an example of which of the following ethical principles?
Explanation
Rationale:
A. Beneficence refers to actions that promote the well-being of others, which is not the primary focus of this scenario.
B. Nonmaleficence involves the duty to do no harm, which is important in all nursing actions but is not specifically demonstrated here.
C. Justice involves fairness and equality in providing care, which is not the central ethical principle in this context.
D. Autonomy refers to respecting a client's right to make their own decisions. By asking the client to choose between morning or afternoon group therapy, the nurse is supporting the client's autonomy by allowing them to make decisions about their care.
A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
Explanation
Rationale:
A. Clients with active tuberculosis should not be placed in a room with other clients, even if they require droplet precautions, as TB requires airborne precautions.
B. While PPE protocols are important, the most critical precaution for TB is ensuring the client is in the correct environment to prevent airborne transmission.
C. Wearing gowns, masks, and gloves is important, but the most essential measure is the room's ventilation system.
D. Active tuberculosis is an airborne infectious disease, so the client should be placed in a private room with a negative pressure ventilation system to prevent the spread of the bacteria through the air.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?
Explanation
Rationale:
A. Removing the PICC line should only be done if directed by a provider after further assessment.
B. The first action is to measure the circumference of both arms to assess for possible complications such as thrombosis or infiltration. This measurement will help determine the extent of the swelling and inform subsequent actions.
C. Notifying the provider is important but should be done after gathering relevant assessment data, such as the arm circumference.
D. Applying a cold pack may be appropriate for reducing swelling but is not the first step. Assessment should come first.
A nurse is planning care for a client who has been brought to the inpatient mental health unit by law enforcement officers after becoming aggressive in a local bar. The nurse should identify that this finding is consistent with which of the following disorders?
Explanation
Rationale:
A. Narcissistic personality disorder involves a grandiose sense of self-importance and a need for admiration, but it is not typically associated with aggressive behavior in public settings.
B. Antisocial personality disorder is characterized by a disregard for the rights of others, impulsivity, and aggressive behavior. Clients with this disorder may engage in unlawful activities and show no remorse for their actions, making this the most likely diagnosis for the client described.
C. Histrionic personality disorder involves attention-seeking behavior and emotionality, but it does not typically manifest in aggressive outbursts.
D. Borderline personality disorder involves instability in relationships, self-image, and emotions, and while it may include impulsivity, it is not primarily associated with aggressive behavior in public settings.
A nurse is caring for a client who has depression. Which of the following noninvasive treatments should the nurse recommend to the client?
Explanation
Rationale:
A. Cognitive behavioral therapy (CBT) is a noninvasive, evidence-based treatment for depression. It helps clients identify and change negative thought patterns and behaviors that contribute to their depression.
B. Deep-brain stimulation is an invasive procedure used for treatment-resistant depression and other neurological conditions.
C. Electroconvulsive therapy (ECT) is a noninvasive but more intensive treatment often used for severe or treatment-resistant depression. However, it is generally not the first line of treatment.
D. Vagal nerve stimulation is a more invasive treatment, typically reserved for cases where other treatments have failed.
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?
Explanation
Rationale:
A. Offering reassurance without addressing the client's immediate concerns may minimize the severity of the situation and delay necessary interventions.
B. Asking the client about the lethality of their plan is crucial for assessing the level of risk and determining the urgency of the intervention required. This information is essential for planning appropriate care and ensuring the client's safety.
C. Allowing the client to be alone is not appropriate when they have expressed suicidal intent, as this could increase the risk of self-harm.
D. Encouraging the client to focus on the positive aspects of life may be part of long-term therapy, but in the acute phase, the priority is to assess and address the immediate risk of suicide.
A nurse has successfully completed a drug treatment program and is returning to work 3 months later. Which of the following best describes a program designed for a nurse returning to work after treatment?
Explanation
Rationale:
A. A drug recovery support group can be beneficial for ongoing support but does not specifically address the work-related needs of a nurse returning to practice.
B. An early-release incarceration program is not relevant to the context of a nurse returning to work after completing treatment for substance abuse.
C. An Alternative-to-Discipline (ATD) program is designed to support healthcare professionals returning to work after treatment for substance use disorders. These programs focus on monitoring and supporting the nurse while ensuring public safety.
D. An involuntary long-term residential treatment is not applicable to a nurse who has already completed a treatment program and is preparing to return to work.
A nurse is caring for a client who has been brought into an emergency department of a large hospital. The client's family state that the client "took some kind of drugs. The client is dizzy, has recently vomited, and is experiencing paranoia, yelling, "Stay away from me! You are going to kill me!" The client alternates yelling with mumbling and gesturing. Their eyes are darting back and forth as they are talking to the wall. The nurse should suspect the client has used which of the following substances?
Explanation
Rationale:
A. Anabolic steroids are associated with mood swings and aggressive behavior but are less likely to cause the acute symptoms of paranoia, hallucinations, and severe agitation described here.
B. Hallucinogens, such as LSD or PCP, can cause intense paranoia, hallucinations, and erratic behavior, as seen in the client’s symptoms. These substances often lead to altered perceptions of reality, including visual and auditory hallucinations.
C. Stimulants like cocaine or methamphetamines can cause paranoia and hyperactivity but are less likely to cause the vivid hallucinations described.
D. Opioids typically cause drowsiness, respiratory depression, and a sense of euphoria rather than hallucinations and severe agitation.
A nurse is planning care for a client who has chronic substance use disorder. Which of the following is the most therapeutic response to help the client cease alcohol consumption?
Explanation
Rationale:
A. Sharing personal experiences can be supportive, but it may not be the most therapeutic or professional approach in this situation.
B. This question is leading and doesn't encourage an open dialogue. It may also induce guilt or defensiveness in the client.
C. This statement is authoritative and may come across as coercive, which can be counterproductive in encouraging the client to take responsibility for their recovery.
D. Collaborating with the client on a comprehensive plan that includes medication, group support, and counseling is a therapeutic approach that empowers the client to actively participate in their recovery, offering them the best chance of success.
A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)
Explanation
Rationale:
A. Protein intake should be limited in clients with CKD to reduce the burden on the kidneys, as excessive protein can accelerate kidney damage.
B. Caloric intake typically needs to be adequate to meet energy requirements, not necessarily limited unless advised by a healthcare provider based on specific health needs.
C. Sodium intake should be restricted to prevent fluid retention and hypertension, which can worsen kidney function.
D. Phosphorous should be limited to avoid hyperphosphatemia, which can lead to bone and cardiovascular problems in CKD patients.
E. Calcium intake is usually maintained or adjusted carefully, rather than broadly limited, to manage bone health and prevent complications associated with CKD.
A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct?
Explanation
Rationale:
A. The cortico-striato-thalamo-cortical circuit (CSTC) is primarily associated with obsessive-compulsive disorder (OCD) and does not directly relate to phobias.
B. While the CSTC circuit is involved in OCD, it is not specifically linked to the broader spectrum of fear responses.
C. The amygdala-centered (ACC) circuit is involved in the processing of fear and panic, making it directly associated with feelings of panic, which are common manifestations of anxiety disorders.
D. The amygdala does play a role in anxiety and apprehension, but it is more specifically tied to the acute panic responses.
Sign Up or Login to view all the 78 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
