A client with schizophrenia tells the nurse, 'I'm being watched constantly by the FBI because of my job.' Which response by the nurse would be most appropriate?

Questions 20

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ATI Mental Health Practice Questions Questions

Question 1 of 9

A client with schizophrenia tells the nurse, 'I'm being watched constantly by the FBI because of my job.' Which response by the nurse would be most appropriate?

Correct Answer: B

Rationale: The correct response is B: "It must be frightening to feel like you're always been watched." This response validates the client's feelings without challenging the delusion directly. It shows empathy and builds rapport. Choice A may inadvertently reinforce the delusion. Choice C denies the client's experience and may lead to resistance. Choice D uses clinical jargon and may be too direct, potentially causing the client to become defensive.

Question 2 of 9

A nurse is preparing a presentation for an adolescent and young adult community group about stalking. Which group would the nurse identify as having the highest risk of being stalked?

Correct Answer: D

Rationale: The correct answer is D (ages 18 to 24 years Women) because young women in this age group are statistically at the highest risk of being stalked. Factors such as increased social media use, dating relationships, and independence make them vulnerable. They may also be more likely to encounter obsessive behaviors from current or former partners. Choice A (Boys and young men) is less likely as stalking affects women more frequently. Choice B (ages 12 to 21 years Men) is less likely as younger age groups are generally at a lower risk. Choice C (ages 24 to 28 years) is less likely as the risk tends to decrease slightly as individuals get older.

Question 3 of 9

What intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?

Correct Answer: A

Rationale: The correct answer is A: referring the client for hypnosis. Hypnosis is an evidence-based nonpharmacologic intervention for chronic pain that can help manage pain perception and improve coping mechanisms. It is safe and effective for long-term pain management. Referring for hypnosis aligns with the holistic approach to chronic pain management. Choice B: administering pain medication as prescribed is a pharmacologic intervention, not nonpharmacologic. Choice C: removing all glaring lights and excessive noise can help create a comfortable environment but may not directly address chronic pain relief. Choice D: using over-the-counter transcutaneous electric nerve stimulation is a nonpharmacologic intervention, but it may not be as effective for chronic pain as hypnosis.

Question 4 of 9

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?

Correct Answer: A

Rationale: The correct answer is A because it promotes cognitive-behavioral techniques to manage anger effectively. By helping the patient identify triggering thoughts, evaluate their validity, and replace them with reality-based thinking, nurses can assist in changing the patient's response to anger. This intervention encourages self-awareness and empowers the patient to develop healthier coping mechanisms. Choice B is incorrect as it promotes punitive measures, which can escalate aggression and undermine trust between the patient and healthcare provider. Choice C is incorrect as aversive conditioning methods like popping a rubber band on the wrist are not evidence-based and can be harmful. Choice D is incorrect as medication should not be the first-line intervention for managing anger without violence.

Question 5 of 9

A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

Correct Answer: A

Rationale: The correct answer is A because a client placed in restraints due to aggressive behavior poses an immediate safety concern that requires urgent assessment to prevent harm to the client or others. Assessing this client first ensures their immediate well-being. Choice B may indicate a potential health issue but does not pose an immediate safety threat, so it can be assessed after addressing the client in restraints. Choice C, a client receiving PRN medication for anxiety, may require assessment but does not present the same level of urgency as a client in restraints. Choice D, a client receiving ECT treatment, is important but not as urgent as the client in restraints. It can be assessed after addressing the immediate safety concern.

Question 6 of 9

The nurse administers each of the following drugs to various patients. The patient who should be most carefully assessed for fluid and electrolyte imbalance is the one receiving:

Correct Answer: A

Rationale: The correct answer is A: Lithium (Eskalith). Lithium is known to cause fluid and electrolyte imbalances by affecting sodium and water reabsorption in the kidneys. Patients on lithium therapy should be closely monitored for signs of dehydration, hyponatremia, and other electrolyte disturbances. Clozapine, Diazepam, and Amitriptyline do not typically cause significant fluid and electrolyte imbalances. Monitoring is still important, but not as critical as with lithium.

Question 7 of 9

A nursing student observes an incorrect dosage of medication being given to a client receiving electroconvulsive therapy. To implement the ethical principle of veracity, which action would the nursing student take?

Correct Answer: B

Rationale: The correct answer is B. By informing the student's instructor and the client's primary nurse, the nursing student upholds the ethical principle of veracity, which is being truthful and honest. This action ensures that the correct dosage of medication is administered to the client, preventing potential harm. Documenting the situation is essential for accurate record-keeping and accountability. Choice A is incorrect because keeping the information confidential would go against the ethical principle of veracity and could potentially harm the client. Choice C is incorrect as the decision about actions should involve healthcare professionals to ensure the client's safety and well-being, not solely the client. Choice D is incorrect because even if the client was not harmed immediately, incorrect medication dosages could still have long-term consequences, making it crucial to report the incident for proper evaluation and prevention.

Question 8 of 9

A client with schizophrenia tells the nurse, 'I'm being watched constantly by the FBI because of my job.' Which response by the nurse would be most appropriate?

Correct Answer: B

Rationale: The correct response is B: "It must be frightening to feel like you're always been watched." This response validates the client's feelings without challenging the delusion directly. It shows empathy and builds rapport. Choice A may inadvertently reinforce the delusion. Choice C denies the client's experience and may lead to resistance. Choice D uses clinical jargon and may be too direct, potentially causing the client to become defensive.

Question 9 of 9

The nurse is caring for an older patient in a residential care facility. The patient has been extremely irritable the entire day. When modifying the patient's plan of care, which of the following would be an appropriate snack to offer the patient to decrease the irritability?

Correct Answer: D

Rationale: The correct answer is D: Glass of milk. Milk contains tryptophan, an amino acid that helps in the production of serotonin, a neurotransmitter that contributes to mood regulation. Offering the patient a glass of milk can help increase serotonin levels, potentially decreasing irritability. A: Chocolate candy bar is high in sugar and may lead to a spike in blood sugar levels, followed by a crash, which can worsen irritability. B: Raisins are a source of natural sugars but lack the necessary nutrients to help regulate mood. C: Granola bar may contain added sugars and lack the specific components like tryptophan found in milk to help improve mood.

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