When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be

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Mental Health Assessment ATI Capstone Questions

Question 1 of 5

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be

Correct Answer: A

Rationale: The correct answer is A: "Are you having difficulty hearing when I speak?" This is the most appropriate question as the patient's leaning forward and frowning could indicate potential hearing difficulties. By asking this question, the nurse can address a possible communication barrier and provide necessary accommodations. Option B, "How can I make this assessment interview easier for you?" is more general and may not directly address the specific issue of hearing difficulty. Option C, "I notice you are frowning. Are you feeling annoyed with me?" assumes the patient's emotions without addressing the potential hearing issue. Option D, "You're having trouble focusing on what I'm saying. What is distracting you?" assumes a focus issue rather than considering hearing impairment.

Question 2 of 5

A nurse is interviewing a client who has a co-occurring diagnosis. The client is trying to explain why it is so easy to start drinking again even though hospitalization and prescribed medications can eventually control his mental problems. Which statement by the client would the nurse interpret as reflecting the client's beliefs?

Correct Answer: B

Rationale: Rationale: The correct answer is B because it reflects the client's belief that drinking provides an escape from negative emotions and a sense of euphoria that medication cannot offer. This statement indicates the client's preference for the emotional effects of alcohol over the functional benefits of medication. Summary of other choices: A: Focuses on the financial aspect and convenience of alcohol, not the emotional aspect. C: Highlights issues with side effects and forgetfulness, not the emotional appeal of alcohol. D: Mentions avoiding responsibility as a reason for not taking medication, rather than seeking emotional relief from alcohol.

Question 3 of 5

A client's blood level of carbamazepine is increased. When reviewing the client's medication history, which of the following would alert the nurse to a possible interaction?

Correct Answer: D

Rationale: Step 1: Carbamazepine is metabolized by CYP3A4 enzyme. Step 2: Diltiazem is a CYP3A4 inhibitor. Step 3: Inhibiting CYP3A4 can lead to increased carbamazepine levels. Step 4: Therefore, Diltiazem can interact with carbamazepine. Summary: A, B, and C are not CYP3A4 inhibitors, so they are less likely to interact with carbamazepine compared to Diltiazem.

Question 4 of 5

The spouse of a patient diagnosed with schizophrenia says, 'I don't understand how events from childhood have anything to do with this disabling illness.' Which response by the nurse will best help the spouse understand the cause of this disorder?

Correct Answer: C

Rationale: The correct answer is C: Research shows that this condition more likely has a biological basis. Schizophrenia is a complex disorder with strong evidence pointing to a biological origin, such as genetics and brain structure abnormalities. By emphasizing the biological basis, the nurse can help the spouse understand that it is not solely related to childhood events. Incorrect Choices: A: Psychological stress is the basis of most mental disorders - This statement is too general and not specific to schizophrenia. B: This illness results from developmental factors rather than stress - While developmental factors may play a role, research indicates a strong biological component in schizophrenia. D: It must be frustrating for you that your spouse is sick so much of the time - This response does not address the cause of schizophrenia and focuses on the spouse's feelings instead.

Question 5 of 5

What safety-related responsibility does the nurse have in any situation of suspected abuse?

Correct Answer: D

Rationale: The correct answer is D because reporting suspected abuse to the proper authorities is a legal and ethical requirement for healthcare professionals to protect vulnerable individuals. Reporting ensures that the appropriate agencies can investigate and intervene to safeguard the victim. Choice A is incorrect as it focuses solely on future prevention rather than immediate action. Choice B is incorrect as it may compromise the safety of the victim by alerting the abuser. Choice C is incorrect as counseling is not the primary responsibility when abuse is suspected, reporting is.

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