a nurse is conducting a mental status examination on a client which of the following components shouldnt be included in the assessment
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Nursing Elites

ATI RN

ATI Mental Health

1. During a mental status examination, which of the following components should not be included in the assessment?

Correct answer: B

Rationale: During a mental status examination, components such as appearance and behavior, mood and affect, and cognitive function are assessed. Giving advice is not a component of a mental status examination as it focuses on evaluating the client's mental state rather than providing guidance or recommendations.

2. Which characteristic identified during an assessment serves to support a diagnosis of disruptive mood dysregulation disorder? Select one that doesn't apply.

Correct answer: C

Rationale: Characteristics such as age, frequency of outbursts, and occurrence in multiple settings support a diagnosis of disruptive mood dysregulation disorder. While comorbid conditions like autism can coexist with disruptive mood dysregulation disorder, it is not a characteristic that serves to support a diagnosis of this specific disorder.

3. A client has been diagnosed with borderline personality disorder, and a nurse is providing care. Which intervention should the nurse implement to promote the client's safety?

Correct answer: A

Rationale: Implementing a no-harm contract is a crucial intervention for clients with borderline personality disorder as it helps establish an agreement between the client and the healthcare provider to abstain from self-harming behaviors. This contract aims to promote the client's safety by enhancing awareness and providing a structured approach in managing impulses and emotions.

4. What information should the nurse provide in patient education for a patient prescribed sertraline for major depressive disorder?

Correct answer: B

Rationale: Patients prescribed sertraline for major depressive disorder should be educated that it may take several weeks before experiencing the full therapeutic effects of the medication. This delay in onset of action is common with antidepressants like sertraline, and patients need to be aware of this to manage their expectations and continue with the treatment regimen. It's important for the patient to understand that consistent adherence to the prescribed dosage is crucial, even if the full effects are not immediately apparent. Choices A, C, and D are incorrect because taking the medication with food, avoiding grapefruit, and regular blood tests are not specific education points related to the expected timeframe for therapeutic effects of sertraline.

5. A client with depression is experiencing anhedonia. Which statement by the client reflects this symptom?

Correct answer: B

Rationale: Anhedonia is the inability to experience pleasure from activities usually found enjoyable. The statement 'I don't enjoy the things I used to love' directly reflects this symptom as the client is expressing a lack of pleasure from previously enjoyable activities. Choices A, C, and D do not specifically relate to anhedonia but rather indicate symptoms of anxiety, concentration difficulties, and sleep disturbances, respectively.

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