ATI RN
ATI RN Mental health 2019 NGN II Questions
Question 1 of 5
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Sore throat. This finding is a priority to report because clozapine can cause agranulocytosis, which is a severe reduction in white blood cells, leading to increased risk of infection. A sore throat could indicate an infection, which can progress rapidly in a client with lowered immunity. Reporting this promptly allows for timely intervention to prevent serious complications.
Other choices are less urgent:
A: Random blood glucose of 130 mg/dL is slightly elevated but not a priority over infection risk.
B: Nausea is a common side effect of clozapine and can be managed symptomatically.
C: Heart rate of 104/min may be due to various factors and does not require immediate intervention.
Question 2 of 5
A nurse is assessing a client who has a history of substance use disorder and states,"People are out to get me. The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
Correct Answer: D
Rationale: The correct answer is D: Cocaine. The client's symptoms of paranoia, tachycardia, and hypertension are indicative of acute toxicity from stimulant substances like cocaine. Cocaine can cause paranoia, increased heart rate, and elevated blood pressure. Alcohol (
A) typically presents with depressive effects, not paranoia. Heroin (
B) and opium (
C) are opioids, which would cause respiratory depression and sedation, not paranoia or tachycardia.
Therefore, the correct choice is D: Cocaine.
Question 3 of 5
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
Correct Answer: C
Rationale: The nurse should see client C first because clozapine, an antipsychotic medication, can cause agranulocytosis which presents with sore throat as an early sign. This is a potentially life-threatening condition that requires immediate attention to prevent complications. Clients A and B are displaying symptoms related to their mental health conditions but are not indicating urgent medical issues. Client D reporting weight gain is a common side effect of lithium and does not require immediate intervention compared to potential agranulocytosis in client C.
Question 4 of 5
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Withhold the next dose of the medication. This is the correct action because lamotrigine is known to cause a serious rash called Stevens-Johnson Syndrome. By withholding the next dose, the nurse can prevent further exacerbation of the rash and protect the client from potential harm. Asking about laundry detergent (
B) is irrelevant as the rash is likely medication-related. Applying hydrocortisone cream (
C) may not address the underlying cause and could worsen the rash. Explaining the rash as temporary (
D) is incorrect as it could be a serious side effect.
Question 5 of 5
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Reacting to the nurse as though she were his mother. In transference, the client projects feelings onto the nurse based on past relationships. This behavior is common in clients with personality disorders.
Choice A is incorrect as it relates to general frustration, not transference.
Choice C is incorrect as it pertains to avoidance, not transference.
Choice D is incorrect as it involves negativity towards staff, not transference. In summary, only choice B aligns with the concept of transference in this scenario.