ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A patient with major depressive disorder is receiving fluoxetine (Prozac). The nurse notices that the patient has started to exhibit restlessness, tremors, and confusion. What should the nurse do first?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Withhold the fluoxetine and notify the healthcare provider. This is the most appropriate action for the nurse to take first. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. The symptoms of restlessness, tremors, and confusion exhibited by the patient indicate a potential for serotonin syndrome, a serious and potentially life-threatening condition caused by excessive serotonin levels in the body. Withholding the fluoxetine and notifying the healthcare provider is crucial to prevent further escalation of symptoms and ensure the patient's safety. Option A) Increasing the patient's fluoxetine dosage would be contraindicated in this situation as it could exacerbate the symptoms of serotonin syndrome. Option C) Providing an anti-anxiety medication is not the first-line intervention for the symptoms described. Addressing the underlying cause, in this case, the potential serotonin syndrome, should take precedence. Option D) Monitoring the patient for more symptoms of serotonin syndrome is important, but the immediate action should be to withhold the fluoxetine and seek guidance from the healthcare provider. In an educational context, this scenario highlights the importance of recognizing and managing potential adverse effects of psychotropic medications. Nurses caring for patients with mental health conditions need to be vigilant in monitoring for medication side effects and knowing the appropriate interventions to ensure patient safety and well-being. Early recognition and prompt action in response to adverse drug reactions are essential components of safe and effective nursing care in behavioral health settings.
Question 2 of 5
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse what type of essential oils should be used when the client receives massage therapy to decrease anxiety. Which of the following oils should the nurse recommend?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Rosemary. Rosemary essential oil is known for its calming and stress-reducing properties, making it an ideal choice to help decrease anxiety in individuals with Alzheimer's disease during massage therapy. Eucalyptus (option A) is more commonly used for respiratory issues and may not have the same calming effects as rosemary. Frankincense (option C) is often used for relaxation and spiritual purposes, but it may not be as effective in reducing anxiety as rosemary. Cypress (option D) is known for its astringent properties and is not typically used for anxiety relief. From an educational standpoint, it is important for nurses to have a good understanding of essential oils and their therapeutic properties to provide safe and effective care to clients with Alzheimer's disease. Recommending the appropriate essential oil can enhance the overall therapeutic benefits of massage therapy and improve the client's well-being. Nurses should also consider individual preferences, allergies, and sensitivities when recommending essential oils for therapeutic use.
Question 3 of 5
A nurse is caring for a client who has post-traumatic stress disorder and is considering prolonged exposure therapy. The client asks, 'How does this therapy work?' Which of the following responses by the nurse accurately describes this type of therapy?
Correct Answer: B
Rationale: The correct answer is B) A therapist helps you safely and gradually face memories or situations related to your trauma that evoke fear. Prolonged exposure therapy is a type of cognitive-behavioral therapy commonly used to treat post-traumatic stress disorder (PTSD). This therapy works by gradually exposing the individual to their traumatic memories or situations in a safe and controlled environment. By facing these experiences repeatedly over time, the individual can learn to process and reduce the fear associated with the trauma, ultimately leading to a decrease in PTSD symptoms. Option A is incorrect because it describes eye movement desensitization and reprocessing (EMDR) therapy, which involves focusing on eye movements while recalling traumatic experiences, but it does not involve exposure to the trauma itself. Option C describes talk therapy or psychotherapy focused on self-awareness and behavior change, which is not specific to the exposure-based approach of prolonged exposure therapy for PTSD. Option D describes cognitive therapy, which focuses on understanding and changing thought patterns and behaviors but does not involve exposure to traumatic memories as in prolonged exposure therapy. In an educational context, it is crucial for nurses to understand different types of therapy for mental health conditions like PTSD to provide accurate information to clients. Understanding the rationale behind each therapy helps nurses support clients in making informed decisions about their treatment options.
Question 4 of 5
A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient states, 'I don't need to sleep. I feel great!' Which of the following is the priority nursing diagnosis for this patient?
Correct Answer: B
Rationale: In this scenario, the priority nursing diagnosis for a patient with bipolar disorder in the manic phase stating "I don't need to sleep. I feel great!" is option B) Risk for injury related to impulsive and reckless behavior. This is the correct choice because during the manic phase, individuals often engage in risky behaviors due to their elevated mood and decreased impulse control. The patient's statement indicates a lack of recognition of the need for sleep, which can lead to increased impulsivity and potential harm. Option A is incorrect as disturbed sleep pattern, though important, is secondary to the immediate risk of injury. Option C is incorrect because while imbalanced nutrition may occur in bipolar disorder, the safety concern of impulsive behavior takes precedence. Option D is incorrect as ineffective coping is a concern, but the immediate risk of injury due to reckless behavior is the priority in this case. Educationally, understanding the hierarchy of nursing diagnoses in managing patients with bipolar disorder is crucial. Prioritizing safety concerns and addressing immediate risks is fundamental in providing effective care for individuals experiencing manic episodes. It is essential for nurses to recognize and respond to potential harm that may result from impulsive behaviors during the manic phase.
Question 5 of 5
A nurse is teaching a patient diagnosed with anorexia nervosa about healthy eating habits. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: In this scenario, option B, "I plan to eliminate all fats from my diet to lose weight," indicates the need for further education. This statement reflects a common misconception that all fats are unhealthy, which is not true. Fats are essential for overall health and should be consumed in moderation. Option A demonstrates a good understanding of the importance of eating small, frequent meals to support weight restoration and overall health, making it a correct choice. Option C also shows a good understanding by recognizing the need to gradually increase caloric intake to achieve a healthy weight. Option D reflects a comprehensive understanding that a balanced diet with a variety of foods is crucial for improving overall health. In an educational context, it is important to emphasize to patients with anorexia nervosa that a balanced approach to nutrition is key. Educating them about the different food groups, portion sizes, and the importance of including healthy fats, proteins, and carbohydrates in their diet is essential. This will help them develop a healthier relationship with food and support their recovery journey.