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Total Questions : 16

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Question 1:

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Answer and Explanation

Choice A:

Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B:

While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D:

Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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Question 2:

A nurse is preparing to administer 1500 mL of IV fluid to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/h?

Answer and Explanation

Correct Answer: "750" mL/h

Explanation

Calculation steps:

Step 1: Determine the total volume to be infused. 1500 mL

Step 2: Determine the time for infusion. 2 hours

Step 3: Calculate the rate in mL/h. 1500 mL ÷ 2 hours Result: 750 mL/h

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Question 3:

A nurse is caring for a client who was admitted with major depressive disorder. The nurse and client find that they have much in common, including each having a neighbor's son. They make plans to have dinner and a sleepover with their sons after the client is discharged. What does this situation reflect?

A. A strong professional relationship. B. Countertransference. C. Successful relationship building. D. Boundary blurring.

Answer and Explanation

Choice A:

A strong professional relationship does not involve personal plans outside of the therapeutic context.

Choice B:

Countertransference refers to the nurse's emotional response to the client, not planning personal activities together.

Choice C:

Successful relationship building occurs within professional boundaries and does not involve personal plans.

Choice D:

The correct answer is d) because making personal plans with a client blurs the boundaries of the professional therapeutic relationship, which can affect the nurse's objectivity and professionalism.

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Question 4:

A nurse is teaching a client who has a fear of heights about the use of systematic desensitization as a method of behavioral therapy. Which of the following client statements indicates an understanding of the teaching?

A. "I will be asked to imitate my therapist's actions around heights." B. "I will snap a rubber band on my wrist when heights scare me." C. "I will need to stand on a very high place until I am calm." D. "I will slowly be exposed to places of increasing height."

Answer and Explanation

Choice A:

Systematic desensitization does not involve imitating the therapist's actions.

Choice B:

Snapping a rubber band on the wrist is a different behavioral technique (aversion therapy), not systematic desensitization.

Choice C:

Standing on a very high place until calm is not systematic desensitization, which involves gradual exposure.

Choice D:

The correct answer is d) because systematic desensitization involves gradually increasing exposure to the feared stimulus (heights) to reduce the fear response.

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Question 5:

A client newly placed on an involuntary hold is being given an orientation to the psychiatric unit. The nurse includes information about the client's rights. Which of the following statements should the nurse include? Select all that apply.

A. "You have the right to refuse prescribed treatment." B. "You have the right to mail out letters." C. "You have the right to file grievances against staff." D. "You have the right to a private room." E. "You have the right to conduct religious practices."

Answer and Explanation

Choice A:

Clients on an involuntary hold may not have the right to refuse treatment if it is deemed necessary for their safety.

Choice B:

The correct answer is b) because clients have the right to communicate with others, including mailing letters.

Choice C:

The correct answer is c) because clients have the right to file grievances against staff if they feel their rights are being violated.

Choice D:

A private room is not a guaranteed right for clients on an involuntary hold.

Choice E:

The correct answer is e) because clients have the right to practice their religion and conduct religious practices.

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Question 6:

A nurse is administering oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse perform?

A. Refer the case to the facility's ethics committee. B. Document the client's refusal of the medication in the medical record. C. Administer the medication by another route. D. Inform the client that due to her involuntary admission, she cannot refuse a sedative.

Answer and Explanation

Choice A:

Referring the case to the ethics committee is not the immediate action required.

Choice B:

The correct answer is b) because documenting the client's refusal ensures that it is noted in the medical record and appropriate follow-up actions can be taken.

Choice C:

Administering the medication by another route without consent is not appropriate.

Choice D:

Informing the client that she cannot refuse medication due to involuntary admission is not accurate; clients retain certain rights even when involuntarily admitted.

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Question 7:

A charge nurse is discussing examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select the 3 that apply.)

A. To assess cognitive ability, ask the client to write a sentence. B. To assess mood, observe facial expression. C. To assess cognitive ability, ask the client to count backward by sevens. D. To assess appearance, take note of the client's nutritional status. E. To assess recent memory, have the client repeat a list of objects. F. To assess the client's abstract thinking, ask the client to identify our most recent presidents.

Answer and Explanation

Choice A:

The correct answer is a) because asking the client to write a sentence helps assess cognitive ability, including language and writing skills.

Choice B:

Observing facial expression assesses mood, but it is not one of the three selected for understanding cognitive ability.

Choice C:

Counting backward by sevens assesses cognitive function, but it is not selected in this question.

Choice D:

The correct answer is d) because taking note of the client's nutritional status is part of assessing appearance.

Choice E:

The correct answer is e) because asking the client to repeat a list of objects assesses recent memory.

Choice F:

Asking the client to identify recent presidents assesses abstract thinking but is not one of the three selected for understanding the teaching.

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Question 8:

A very anxious client is hesitant to start a new medication and asks the nurse for guidance. The nurse responds, "I'm happy to review the side effects with you and discuss the pros and cons. This may help you make an informed decision, and I support you." In this scenario, the nurse is upholding the client's:

A. Autonomy B. Beneficence C. Fidelity D. Veracity

Answer and Explanation

Choice A:

The correct answer is a) because the nurse is supporting the client's right to make an informed decision about their treatment.

Choice B:

Beneficence involves doing good and acting in the best interest of the client, but the focus here is on supporting the client's decision-making.

Choice C:

Fidelity refers to being faithful and keeping promises, which is not the primary focus in this scenario.

Choice D:

Veracity refers to truthfulness, but the primary focus here is on supporting the client's autonomy.

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Question 9:

A nurse is preparing to administer diazepam 4 mg IV bolus stat. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

Answer and Explanation

Correct Answer: "0.8" mL

Explanation

Calculation steps:

Step 1: Identify the dosage required. 4 mg

Step 2: Identify the concentration available. 5 mg/mL

Step 3: Calculate the volume to be administered. 4 mg ÷ 5 mg/mL Result: 0.8 mL

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Question 10:

A nurse is caring for a client who was admitted to the mental health unit for treatment. The client states, "I am a nurse on the medical-surgical unit, and I don't want my coworkers to know." Which of the following actions should the nurse take?

A. Explain to the client that there is a legal obligation to share information. B. Advise the client that her supervisor will be informed. C. Tell the client her coworkers' opinions should not matter. D. Inform the client that the information will be shared with the treatment team.

Answer and Explanation

Choice A:

Explaining a legal obligation to share information is not accurate in this context.

Choice B:

Advising the client that her supervisor will be informed is not necessary or appropriate.

Choice C:

Telling the client her coworkers' opinions should not matter does not address the confidentiality concern.

Choice D:

The correct answer is d) because informing the client that the information will be shared with the treatment team addresses the need for confidentiality while ensuring the team has the necessary information for treatment.

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Ati n222 mental health quiz

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