ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?
Correct Answer: D
Rationale: The correct answer is D. Clozapine is associated with a serious side effect called agranulocytosis, which can manifest as flu-like symptoms such as fever, sore throat, and malaise. Agranulocytosis is a potentially life-threatening condition that requires immediate medical attention to prevent complications. Clients taking clozapine should be monitored closely for signs of infection.
Choices A, B, and C describe common side effects of antipsychotic medications that are not typically considered emergencies. For example, dizziness upon standing (
A), vomiting (
B), and daytime drowsiness (
C) are known side effects that may not require immediate medical attention unless severe or persistent.
Therefore, the client taking clozapine with flu-like manifestations (
D) should be seen by a provider immediately due to the potential seriousness of agranulocytosis.
Question 2 of 5
A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse’s assessment priority?
Correct Answer: C
Rationale: The correct answer is C: Suicide risk. This is the priority assessment because the client is reporting symptoms of depression and anxiety, which are risk factors for suicide. Assessing suicide risk is crucial for ensuring the client's safety. Coping abilities (
A) and support systems (
B) are important, but assessing suicide risk takes precedence in this situation. Psychiatric history (
D) may provide valuable information, but it is not the priority when the client is actively reporting symptoms of depression and anxiety.
Question 3 of 5
A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. The priority in caring for a client experiencing acute alcohol withdrawal is to prevent potential life-threatening complications like seizures. Implementing seizure precautions involves ensuring a safe environment, such as padding the bed and removing any harmful objects. This step takes precedence over inserting an IV access site (
B) or obtaining a blood specimen (
C) because seizures pose an immediate risk to the client's safety. It is crucial to address the most urgent need first to ensure the client's well-being.
Question 4 of 5
A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse’s priority response?
Correct Answer: C
Rationale: The correct answer is C: "Have you thought of harming yourself?" because it addresses the immediate safety concern of suicidal ideation. It is crucial to assess the client's risk of self-harm or suicide first.
Choice A is not a direct inquiry about self-harm.
Choice B focuses on the current situation but does not address the suicidal statement.
Choice D is more about exploring the history of depressive symptoms rather than assessing immediate risk.
Question 5 of 5
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse’s priority?
Correct Answer: A
Rationale: The correct answer is A: Monitor for risk of self-harm. This is the priority because individuals with major depressive disorder are at an increased risk for suicide. The nurse must ensure the client's safety by closely monitoring for any signs of self-harm or suicidal ideation. Administering antidepressants (
B) may be important for long-term management but ensuring immediate safety takes precedence. Encouraging fluid intake (
C) and assisting with activities of daily living (
D) are important aspects of care but do not address the immediate risk of self-harm.