ATI RN
ATI N200 Mental Health Exam 3 Questions
Question 1 of 5
A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:
Correct Answer: A
Rationale: The correct answer is A: There are any signs of infection. Clozapine can cause agranulocytosis, a serious side effect that suppresses the immune system, leading to an increased risk of infection.
Therefore, any signs of infection such as fever, sore throat, or flu-like symptoms must be reported immediately to the physician to monitor for agranulocytosis.
Choice B is incorrect because a decrease in hallucinations is a therapeutic effect of clozapine and should be expected.
Choice C is incorrect as a decrease in appetite is a common side effect of clozapine and usually improves over time.
Choice D is incorrect as insomnia is a common side effect of clozapine and does not require immediate medical attention.
Question 2 of 5
A client tells the nurse,"I feel bad because my mother does not want me to return home after I leave the hospital. Which nursing response is most therapeutic?
Correct Answer: D
Rationale: The correct answer is D because it reflects active listening and empathy towards the client's feelings. By restating the client's statement ("You feel that your mother does not want you to come back home"), the nurse validates the client's emotions and encourages further exploration and discussion. This response shows support and understanding without making assumptions or judgments.
Choice A is incorrect as it assumes the mother is understanding without knowing the full situation.
Choice B is invalidating and dismissive of the client's emotions.
Choice C puts pressure on the client to confront their mother without acknowledging their current emotional state.
Question 3 of 5
A young client asks the nurse for their telephone number,with the intent of calling to schedule a date. Which of the following responses would be most appropriate?
Correct Answer: C
Rationale: The correct answer is C: "This is a professional relationship, and we need to be clear on that." This response establishes professional boundaries, prioritizing the therapeutic relationship over personal interests. It communicates respect for the client and maintains ethical standards. Other choices are incorrect: A implies a potential relationship after recovery, which blurs boundaries; B cites policy rather than explaining the nature of the relationship; D discloses personal information that is not relevant to the situation.
Question 4 of 5
Upon assessment of the lungs,the nurse hears continuous high-pitched musical sounds. This should be documented as:
Correct Answer: A
Rationale: The correct answer is A: Wheezes. Wheezes are continuous high-pitched musical sounds typically heard during expiration, indicating narrowed airways. Rhonchi are low-pitched snoring or rattling sounds caused by secretions in larger airways. Fine crackles are discontinuous, high-pitched sounds heard during inspiration, caused by fluid in smaller airways. Vesicular sounds are normal breath sounds heard over most of the lung fields. In this scenario, the description matches wheezes best, indicating airway constriction.
Question 5 of 5
The nurse notices a client wandering in the hospital hall giggling,with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:
Correct Answer: D
Rationale: The correct answer is D: Provide a safe environment. This is the priority because the client's behavior is potentially dangerous to herself and others. Providing a safe environment involves ensuring the client is not at risk of harm, such as falling or wandering outside. Encouraging social interaction (
A) may not be appropriate given the client's current behavior. Discussing the bizarre behavior (
B) may escalate the situation. Giving information about her illness (
C) may not be effective in managing the immediate safety concerns.