ATI Custom NUR 316 Fall 2023 1MHE Module 4 - 1st 5 units | Nurselytic

Correct Answer: A

Rationale: The correct answer is A: Ask the client about the lethality of their plan. This is the correct action because assessing the lethality of the client's plan is crucial in determining the level of risk and the necessary interventions. By understanding the specifics of the plan, the nurse can assess the immediacy and severity of the situation, enabling appropriate interventions to be implemented promptly. Encouraging the client to focus on the positive aspects of life (
B) may overlook the seriousness of the situation. Reassuring the client that everything will work out (
C) may minimize the client's feelings and not address the immediate risk. Allowing the client time alone to self-reflect (
D) can be dangerous if the plan is highly lethal.

Correct Answer: A

Rationale:
Correct
Answer: A: The stress from my new job could be the cause of my depressed mood.


Rationale: Stress is a common trigger for depression. Acknowledging the impact of a new job on mental well-being shows an understanding of how external factors can contribute to mood changes. This client statement demonstrates insight into the potential link between stress and depression.

Summary:
B: High blood pressure is a physical health condition and not typically directly linked to depressed mood.
C: Elevated heart rate may indicate anxiety or stress, but it is not a direct cause of depression.
D: Renal dysfunction is a medical issue that may affect mood indirectly but is not a common primary cause of depression.

Correct Answer: A

Rationale: The correct answer is A because stress is a common cause of depressed mood. Stress can lead to feelings of sadness and hopelessness. High blood pressure (
B), elevated heart rate (
C), and renal dysfunction (
D) are not typically direct causes of depressed mood. High blood pressure and elevated heart rate are more closely associated with physical health, while renal dysfunction is related to kidney function, not mental health.
Therefore, A is the best choice as it aligns with common triggers of depression.

Correct Answer: B

Rationale: The correct answer is B: Tardive dyskinesia. The Abnormal Involuntary Movement Scale (AIMS) assessment is used to evaluate abnormal involuntary movements, such as repetitive, involuntary movements of the face, limbs, and trunk. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications, characterized by these involuntary movements. AIMS helps monitor and assess the severity of tardive dyskinesia in patients taking antipsychotic medications.

Choices A, C, and D are incorrect because they do not specifically relate to the purpose of the AIMS assessment. Opiate withdrawal (
A) is assessed using different tools, alcohol withdrawal (
C) is evaluated using different criteria, and lithium toxicity (
D) is identified through blood tests and clinical symptoms.

Correct Answer: B

Rationale: The correct answer is B: Depersonalization. In panic level anxiety, individuals may experience feelings of detachment from oneself, known as depersonalization. This is a common symptom where individuals feel like they are observing themselves from outside their bodies. This finding is expected in clients experiencing severe anxiety. Shakiness (
A) is more common in mild to moderate anxiety levels. Voice tremors (
C) may occur but are not specific to panic level anxiety. Poor concentration (
D) is a common symptom of anxiety but not specific to panic level anxiety.