A nurse has formulated several nursing diagnoses for a homeless client after a thorough nursing assessment. Of these, which of the following would the nurse determine as the priority?

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ATI Capstone Mental Health Questions

Question 1 of 5

A nurse has formulated several nursing diagnoses for a homeless client after a thorough nursing assessment. Of these, which of the following would the nurse determine as the priority?

Correct Answer: C

Rationale: The correct answer is C: Imbalanced nutrition. This is the priority because it addresses the client's physiological needs, which are essential for survival and overall well-being. The nurse should prioritize addressing basic needs such as nutrition before addressing psychological or social needs. Anxiety (A), powerlessness (B), and impaired social interaction (D) are important but secondary to addressing the client's immediate physiological needs. It is important to address the most critical issue first to ensure the client's health and safety.

Question 2 of 5

The nurse is planning care for a newly admitted adolescent who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?

Correct Answer: A

Rationale: The correct answer is A: Initiate droplet precautions for the client. This is appropriate because bacterial meningitis is transmitted through droplets, so implementing droplet precautions helps prevent the spread of infection to others. Option B (Assist the client to a supine position) is incorrect as it can worsen intracranial pressure. Option C (Perform the Glasgow coma scale every 24 hours) is not directly related to preventing transmission of infection. Option D (Recommend prophylactic acyclovir for the client's family) is incorrect as acyclovir is used for herpes simplex virus, not bacterial meningitis.

Question 3 of 5

Tammy, a 28-year-old with major depressive disorder and bulimia nervosa, is ready for discharge from the county hospital after 2 weeks of inpatient therapy. Tammy is taking citalopram (Celexa) and reports that it has made her feel more hopeful. With a secondary diagnosis of bulimia nervosa, what is an alternative antidepressant to consider?

Correct Answer: A

Rationale: The correct answer is A: Fluoxetine (Prozac). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is FDA-approved for both major depressive disorder and bulimia nervosa. It is commonly used in treating patients with co-occurring depression and eating disorders, like bulimia nervosa. Fluoxetine has shown efficacy in reducing binge eating and purging behaviors associated with bulimia nervosa. Now, let's analyze the other choices: B: Isocarboxazid (Marplan) is a monoamine oxidase inhibitor (MAOI) that is not commonly used as a first-line treatment for bulimia nervosa. MAOIs have more dietary and drug interaction concerns compared to SSRIs. C: Amitriptyline is a tricyclic antidepressant (TCA) that is not typically preferred for bulimia nervosa due to its side effect profile and overdose risk. D: Duloxetine (Cymbalta)

Question 4 of 5

Martin is a 23-year-old male with a new diagnosis of schizophrenia, and his family is receiving information from a home health nurse. The topic of education is suicide prevention, and the nurse recognizes effective teaching when the mother says:

Correct Answer: B

Rationale: The correct answer is B because suicide risk is indeed highest in the first few years after a schizophrenia diagnosis due to the stress of adjusting to the illness, medication side effects, and stigma. Choice A is incorrect as individuals with schizophrenia have a higher risk of suicide compared to the general population. Choice C is incorrect because confusion is not a significant factor in suicide risk for individuals with schizophrenia. Choice D is incorrect as while suicide risk is elevated in schizophrenia, most individuals diagnosed do not die by suicide.

Question 5 of 5

Guadalupe is the matriarch of a large family. She is terminally ill and none of her family members know her end-of-life wishes. The best action for the nurse is to:

Correct Answer: B

Rationale: The correct answer is B because organizing a family meeting with Guadalupe's permission allows for open communication about her end-of-life wishes. This approach respects her autonomy and ensures her preferences are known. Discussing durable power of attorney (A) may be premature without knowing Guadalupe's wishes. Having a family meeting without her (C) disregards her right to be involved in decision-making. Asking the doctor to inform Guadalupe about her terminal illness (D) should be done by a healthcare provider, not a nurse, and may cause distress without addressing her specific wishes.

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