ATI RN
ATI Custom NUR 316 Fall 2023 1MHE Module 4 - 1st 5 units Questions
Extract:
Question 1 of 5
A nurse at a primary care clinic is assessing a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?
Correct Answer: B
Rationale: The correct answer is B: "I can't get my mind to stop racing at night." This statement is consistent with symptoms of depression such as rumination, insomnia, and racing thoughts. In depression, individuals often experience difficulty controlling their thoughts, leading to insomnia and excessive worrying.
Choices A, C, D, and the remaining options do not align with typical symptoms of depression, as they describe restlessness, physical health issues, increased alertness, and lack of information respectively.
Question 2 of 5
A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye's General Adaptation Syndrome (GAS) explains the possible cause for the adolescent's manifestations?
Correct Answer: C
Rationale: The correct answer is C: Exhaustion Phase. In Selye's General Adaptation Syndrome, the Exhaustion Phase occurs after prolonged exposure to stressors, leading to depleted resources and weakened immune response. In the case of the adolescent with recurring manifestations of influenza, the continued stress from the illness may have led to exhaustion of the body's adaptive mechanisms, making the adolescent more susceptible to infections. The other phases are not applicable in this scenario: A - Adaptive Phase is the initial response to stress, B - Resistance Phase is when the body tries to cope with ongoing stress, and D - Alarm Phase is the immediate reaction to stress.
Question 3 of 5
A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale:
Correct Answer: A: The stress from my new job could be the cause of my depressed mood.
Rationale: Stress is a common trigger for depression. Acknowledging the impact of a new job on mental well-being shows an understanding of how external factors can contribute to mood changes. This client statement demonstrates insight into the potential link between stress and depression.
Summary:
B: High blood pressure is a physical health condition and not typically directly linked to depressed mood.
C: Elevated heart rate may indicate anxiety or stress, but it is not a direct cause of depression.
D: Renal dysfunction is a medical issue that may affect mood indirectly but is not a common primary cause of depression.
Question 4 of 5
A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home?
Correct Answer: A
Rationale: The correct answer is A: Necklace. The nurse should ask the client's partner to take back the necklace because it could potentially be used as a means for self-harm or suicide. Necklaces can be easily manipulated to create ligatures for strangulation. Lace-up tennis shoes, nylon socks, and cotton underwear do not pose the same risk as they cannot be easily used for self-harm in a mental health setting. It is essential to remove any items that could pose a danger to the client's safety.
Extract:
A nurse is caring for a client who has schizophrenia.
Nurses' Notes.
Day 1 1230: A 38-year-old client who has schizophrenia is admitted.
Diagnosed 15 years ago.
Client reports, "I have been hearing voices again telling me to hurt myself.
I hear voices at nighttime so I am not sleeping well.”. Day 1 1730: Vital Signs.
Client consumed 35% of evening meal.
Client appears nervous but reports not hearing voices at this time.
Day 1 1930: Nurse enters client's room.
Client is standing on bed and states, "Do you see that man? He is telling me he is going to hurt me.”. Client pointing to corner of the room.
Client is talking to themselves and states, "I don't want to hurt myself.
Tell the voices to go away!" Nurse asks the client who they are talking to and states, "Tell me more about who is trying to hurt you.”.
Question 5 of 5
The nurse is reviewing the client's medical record.Select the "3" findings that require immediate follow-up by the nurse.
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Hallucinations, delusions, and insomnia are symptoms that indicate a potential mental health issue requiring immediate follow-up. Hallucinations and delusions suggest psychosis, while insomnia may indicate an underlying mental health condition or stress.
Choice A is a common developmental concern, not requiring immediate follow-up.
Choice E, appetite, is less urgent compared to symptoms indicating mental health issues.