ATI RN Mental Health 2023 Exam 3 | Nurselytic

Correct Answer: A

Rationale: The correct answer is A: Implement seizure precautions. Alcohol withdrawal can lead to seizures, so seizure precautions are crucial for safety. Monitoring for orthostatic hypotension (
B) is important but not the priority. Administering methadone hydrochloride (
C) is not indicated for alcohol withdrawal. Acidifying the client's urine (
D) is not relevant to the situation.

Correct Answer: B

Rationale: The correct answer is B. Sitting with a client who has anorexia during mealtimes can be delegated to assistive personnel as it involves providing emotional support and encouragement. This task does not require specialized nursing skills and can be safely performed by assistive personnel under the supervision of a nurse.

Choices A, C, and D involve complex assessments, critical thinking, and specialized skills that should be performed by a licensed nurse. Reinforcing coping mechanisms, discussing relapse prevention, and administering medications all require nursing judgment and expertise. Delegating these tasks to assistive personnel could compromise the quality of care and put the client's safety at risk.

Correct Answer: C

Rationale: The correct answer is C because the client stating they are unable to eat more than once a day indicates potential malnutrition and a risk to their physical health. This finding requires immediate attention as malnutrition can lead to serious complications.
Choice A relates to grief and anger, which are important but not an immediate priority.
Choice B focuses on guilt, which is also significant but does not pose an immediate threat to physical health.
Choice D is about recalling negative experiences, which may indicate emotional distress but does not present an immediate physical risk.

Correct Answer: C

Rationale: The correct answer is C: Ask the client if the medication is causing adverse effects. This is the most appropriate action to improve medication adherence because it addresses a potential barrier to taking the medication regularly. By inquiring about adverse effects, the nurse can assess if the client is experiencing any side effects that may be impacting their ability or willingness to take the medication. By identifying and addressing these issues, the nurse can work with the client to find solutions or alternatives to improve adherence.

Other choices are incorrect:
A: Threatening admission to an inpatient care facility is coercive and not a respectful or effective approach to improving adherence.
B: Discussing provider goals may not directly address the client's challenges with medication adherence.
D: Requesting a second medication without addressing the underlying issues may not solve the problem and can lead to further complications.

Correct Answer: B

Rationale: The correct answer is B: Evaluate progress toward predetermined goals. During the working phase of a therapeutic relationship, the nurse assesses the client's progress towards the goals set during the initial phase. This step is crucial in determining the effectiveness of the interventions and making adjustments as needed. Informing the client about confidentiality rights (choice
A) is important in the orientation phase. Establishing boundaries (choice
C) is relevant in the introductory phase. Setting short- and long-term objectives (choice
D) is typically done in the initial phase.