ATI RN
Psychobiologic Disorders Med Surg 2 Questions
Question 1 of 5
A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 lb in this time frame. Which is the appropriate nursing reply?
Correct Answer: C
Rationale: The correct answer is C: Weight gain is a common but troubling side effect. Weight gain is a well-known side effect of lithium, commonly seen in individuals taking this medication for bipolar disorder. It is essential for the nurse to acknowledge the client's concern and provide accurate information about the medication's potential side effects. Choices A, B, and D are incorrect because weight gain is a known side effect of lithium, and denying or downplaying the client's experience could lead to misunderstanding and lack of trust in the healthcare provider.
Question 2 of 5
The nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, 'You can't do this to me. Do you know who I am?' Which is the priority nursing action in this situation?
Correct Answer: B
Rationale: The correct answer is B: Take the child swimming at the facility's pool. This is the priority action because the client is exhibiting signs of agitation and potential aggression, and physical activity like swimming can help release pent-up energy and reduce stress. It can also serve as a distraction and help de-escalate the situation. A: Asking the child about their feelings may not be effective in this moment of agitation. C: Establishing a behavioral contract requires a calm and cooperative state from the client, which is not the case currently. D: Administering an anxiolytic medication should not be the initial response unless the client's behavior becomes a safety concern and other interventions have failed.
Question 3 of 5
Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, 'I'd rather stay in my room and listen to music. It's easier than thinking about what is happening in my family.' Which nursing diagnosis is most applicable?
Correct Answer: C
Rationale: The correct answer is C: Defensive coping related to adjustment to changes in family relationships. The adolescent's behavior of truancy and assault is a coping mechanism to avoid dealing with the stress and turmoil caused by the parents' divorce. This choice addresses the underlying issue of struggling to adjust to the changes in family dynamics and using defensive coping mechanisms to deal with the emotional distress. A: Chronic low self-esteem is not the most appropriate diagnosis in this case as the behavior exhibited is more related to coping with family changes rather than self-esteem issues. B: Decisional conflict related to school compliance is not the best choice as the behavior is not primarily driven by conflicts related to school requirements. D: Disturbed personal identity related to changing family dynamics is not the most suitable diagnosis as the primary issue lies in the coping mechanism and adjustment to family changes rather than personal identity disturbances.
Question 4 of 5
An adolescent diagnosed with an impulse control disorder says, 'I want to die. I spend my time getting even with people who hurt me.' When asked about a suicide plan, the adolescent replies, 'I'll jump from a bridge near my home. My father threw kittens off that bridge and they died.' Rate the suicide risk.
Correct Answer: D
Rationale: The correct answer is D, High. The adolescent expressing a desire to die, seeking revenge, and having a specific suicide plan indicate a high suicide risk. The adolescent's plan is detailed and connected to a past traumatic event, increasing the likelihood of intent to carry it out. The reference to the father's actions suggests a deep emotional impact and potential for impulsive behavior. Choices A, B, and C are incorrect because the adolescent's statements demonstrate clear indicators of high suicide risk, requiring immediate intervention to ensure safety.
Question 5 of 5
Which assessment findings support a diagnosis of ODD?
Correct Answer: A
Rationale: The correct answer is A because the assessment findings of being negative, hostile, and spiteful toward parents, and blaming others for misbehavior align with Oppositional Defiant Disorder (ODD) criteria. This behavior pattern is a key characteristic of ODD, where individuals often display defiance and hostility towards authority figures. Choice B describes symptoms of Tourette syndrome, not ODD. Choice C describes conduct disorder behaviors, not specific to ODD. Choice D is unrelated to ODD symptoms.