ATI RN
ATI nsg 133 Mental Health Exam 2 Questions
Question 1 of 5
A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, 'Why bother, why bother going on at all?' Which of the following should the nurse recognize as the need for further assessment?
Correct Answer: C
Rationale: The correct answer is C: Risk for suicide. The client's statement indicates feelings of hopelessness and questioning the point of living, which are red flags for potential suicide risk. The nurse should further assess for suicidal ideation, intent, and plan to ensure the client's safety. Complicated grieving (
A) could be a concern, but the client's statement suggests more immediate risk. Chronic pain (
B) and social isolation (
D) are important factors to consider but are not as concerning as the client's expressed hopelessness.
Question 2 of 5
A nurse is educating the community about anxiety disorders. Which of the following should be included as predisposing factors for the development of anxiety disorders? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct answer includes family history of anxiety disorders (
B), being a perfectionist (
D), and excessive caffeine consumption (E) as predisposing factors for anxiety disorders. Family history increases genetic vulnerability. Being a perfectionist can lead to chronic stress and anxiety. Excessive caffeine consumption can increase nervousness and anxiety symptoms. Regular exercise (
A) and meditation practice (
C) are protective factors, reducing anxiety risk. Chronic physical illness (F) can contribute to anxiety, but it's not a common predisposing factor.
Question 3 of 5
Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Duloxetine, are used for generalized anxiety disorder. Which of the following increases the risk for the client developing serotonin syndrome?
Correct Answer: D
Rationale: The correct answer is D: Combining medications that increase serotonin levels. Serotonin syndrome is caused by excessive serotonin levels in the body, leading to symptoms like confusion, agitation, sweating, and rapid heart rate. Combining medications that increase serotonin levels, such as SNRIs like Duloxetine, with other drugs that also increase serotonin levels can result in this dangerous condition. Missing a dose (choice
A) would not directly increase serotonin levels. Taking MAOI medication (choice
B) can also lead to serotonin syndrome but is not specific to the question about SNRIs. Taking SNRIs as directed (choice
C) is the appropriate use and would not increase the risk of serotonin syndrome.
Question 4 of 5
A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?
Correct Answer: D
Rationale: The correct answer is D: The client makes a contract to avoid self-harm. This is the priority goal because individuals with major depressive disorder, especially following a significant loss, are at an increased risk of self-harm or suicide. By having the client make a contract to avoid self-harm, the nurse is addressing the immediate safety and well-being of the client. This goal helps ensure that the client remains safe during a vulnerable time.
A: While it is important for the client to be involved in the care planning process, ensuring safety takes precedence.
B: Identifying positive qualities is beneficial for self-esteem but may not address the immediate safety concerns.
C: Exhibiting expected grieving behaviors is important, but ensuring safety is the priority.
Summary: The priority goal is to address the client's safety by making a contract to avoid self-harm, as this directly addresses the heightened risk associated with major depressive disorder following a significant loss.
Question 5 of 5
The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?
Correct Answer: A
Rationale: The correct answer is A. This statement indicates effective teaching as it aligns with the expected timeline for bupropion to show effects, typically taking at least 2 weeks.
Choice B is incorrect as alcohol should be avoided while taking bupropion due to increased risk of side effects.
Choice C is incorrect as bupropion does not typically cause a slow heartbeat.
Choice D is incorrect as increased salivation and drooling are not common side effects of bupropion.