ATI RN
Adult Behavioral Health Nursing Questions
Question 1 of 5
A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder?
Correct Answer: C
Rationale: In adult behavioral health nursing, understanding the potential causes of delirium is crucial for providing safe and effective care to clients. In this scenario, the correct answer is C) Benzodiazepines. Benzodiazepines are known to be a common cause of delirium in clients, especially in older adults or those with underlying cognitive impairments. These medications can disrupt neurotransmitter balance in the brain, leading to confusion, disorientation, and other symptoms characteristic of delirium. Option A) Sertraline is an antidepressant commonly used in the treatment of depression and anxiety disorders. While it can have side effects, delirium is not a common presentation associated with sertraline use. Option B) Antihistamines are often used for allergy symptoms or as sedatives. While some antihistamines can cause confusion or sedation, they are not typically a primary cause of delirium. Option D) Amphetamines are stimulant medications used to treat conditions like attention-deficit hyperactivity disorder (ADHD). While amphetamines can cause agitation and confusion, they are more likely to result in symptoms of agitation rather than the full spectrum of delirium. Educationally, this question highlights the importance of medication review and monitoring for potential adverse effects in clients experiencing delirium. Nurses must be vigilant in assessing medication profiles to identify and address potential contributors to delirium, ensuring safe and individualized care for clients.
Question 2 of 5
A patient diagnosed with schizophrenia is taking clozapine. Which of the following side effects should the nurse monitor for in this patient?
Correct Answer: A
Rationale: In the context of adult behavioral health nursing, understanding the side effects of medications used to treat psychiatric disorders is crucial for providing safe and effective care to patients. In this scenario, the correct answer is A) Agranulocytosis. Clozapine is an atypical antipsychotic medication commonly used in the treatment of schizophrenia. Agranulocytosis is a potentially life-threatening side effect of clozapine characterized by a severe decrease in white blood cells, specifically granulocytes. Monitoring for signs of agranulocytosis, such as fever, sore throat, and malaise, is essential to promptly intervene and prevent serious complications. Option B) Extrapyramidal symptoms (EPS) are commonly associated with typical antipsychotic medications, not clozapine. Option C) Neuroleptic malignant syndrome (NMS) is a rare, but serious, side effect of antipsychotic medications that typically presents with fever, muscle rigidity, and autonomic instability. Option D) Tardive dyskinesia is a potential side effect of long-term use of antipsychotic medications, characterized by involuntary movements, but it is not specifically associated with clozapine. Educationally, understanding the specific side effect profile of each medication used in psychiatric treatment is essential for nurses to provide comprehensive care, monitor for adverse effects, and collaborate with the healthcare team to ensure patient safety and well-being.
Question 3 of 5
A nurse is working with a patient diagnosed with bipolar disorder during the depressive phase. Which of the following is the most appropriate nursing intervention?
Correct Answer: A
Rationale: In adult behavioral health nursing, working with patients diagnosed with bipolar disorder requires a nuanced understanding of the condition's phases and appropriate interventions. In the depressive phase, the most appropriate nursing intervention is to provide a calm and low-stimulation environment (Option A). This is crucial because individuals in the depressive phase of bipolar disorder often experience heightened sensitivity to stimuli and may benefit from a quiet, soothing environment to prevent exacerbation of symptoms. Encouraging the patient to engage in group therapy and activities (Option B) may not be the best approach during the depressive phase as social interactions and group settings could be overwhelming for the individual. Supporting the patient in making plans for future activities and goals (Option C) may be challenging as individuals in the depressive phase may struggle with feelings of hopelessness and lack of motivation. Promoting physical exercise (Option D) is generally beneficial for individuals with bipolar disorder, but during the depressive phase, it may be difficult for the patient to engage in physical activities due to low energy levels and lack of motivation. Educationally, understanding the specific needs of individuals with bipolar disorder in different phases is essential for providing effective nursing care. It is important for nurses to tailor interventions based on the individual's current phase to promote positive outcomes and support their overall well-being.
Question 4 of 5
The desired outcome for a patient experiencing insomnia is, 'Patient will sleep for a minimum of 5 hours nightly within 7 days.' At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as
Correct Answer: D
Rationale: The correct answer is D) never demonstrated. In this scenario, the patient did not meet the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. The patient's average nightly sleep of 4 hours falls short of the goal, and taking a 2-hour afternoon nap further contributes to sleep fragmentation rather than achieving consolidated nighttime sleep. Option A) consistently demonstrated would be incorrect because the patient did not consistently achieve the desired outcome. Option B) often demonstrated would be inaccurate as the patient did not frequently meet the goal of sleeping for a minimum of 5 hours nightly. Option C) sometimes demonstrated would also be incorrect as the patient did not occasionally achieve the desired outcome. From an educational perspective, this question highlights the importance of setting specific, measurable, achievable, relevant, and time-bound (SMART) goals in nursing practice. It underscores the need for nurses to critically evaluate patient outcomes based on established criteria and adjust interventions accordingly to promote optimal patient care and outcomes in behavioral health nursing.
Question 5 of 5
A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information?
Correct Answer: B
Rationale: In assessing recent memory, asking about what the patient had for breakfast this morning (Option B) is the best choice. This question requires the patient to recall a recent event, demonstrating intact short-term memory. Option A asks about long-term memory, which is not relevant for assessing recent memory. Option C tests general knowledge, not recent memory. Option D tests immediate recall, not recent memory. In an educational context, understanding the nuances of memory assessment is crucial for nurses working in behavioral health. By selecting appropriate questions, nurses can accurately gauge a patient's cognitive function and tailor interventions effectively. Asking about recent events like breakfast helps assess immediate recall and short-term memory, providing valuable insights into the patient's cognitive status.