ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse in an outpatient mental health facility is preparing to administer phenelzine to a client who has been taking this medication for several years. The client reports eating a grilled cheese sandwich and a banana for lunch and is feeling dizzy. Which of the following vital signs should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A: Blood pressure. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause hypertensive crisis if combined with foods high in tyramine, like cheese and bananas. Assessing blood pressure first is critical to monitor for any signs of hypertensive crisis, such as a sudden increase in blood pressure that could lead to serious complications. Respiration, pulse, and temperature are also important to assess, but blood pressure takes precedence in this situation due to the potential life-threatening effects of hypertensive crisis.
Question 2 of 5
A nurse is caring for a client who states, 'I have been having trouble sleeping for the last several months.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale:
Correct
Answer:
A) "You should avoid stressful activities prior to going to sleep."
Rationale:
1. Stressful activities can increase arousal, making it difficult to fall asleep.
2. Avoiding stressors before bed can help the client relax and prepare for sleep.
3. Engaging in calming activities promotes a restful sleep environment.
4. This response addresses the client's sleep issue by suggesting a practical solution.
Summary of Incorrect
Choices:
B) Exercising close to bedtime can increase alertness, making it harder to fall asleep.
C) Taking a nap in the afternoon can disrupt the client's ability to sleep at night.
D) Watching TV in bed can stimulate the brain, making it challenging to unwind and sleep.
Question 3 of 5
A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?
Correct Answer: D
Rationale: The correct answer is D because participating in solitary activities with a client who has mania is a task that can be safely delegated to an assistive personnel. Solitary activities do not require specialized nursing skills and can help the client manage their symptoms in a therapeutic manner. This task can also promote a sense of independence and self-regulation for the client.
A, B, and C are incorrect choices because they involve providing education, obtaining informed consent, or discussing medication-related information, which require a higher level of knowledge, critical thinking, and communication skills that are typically within the scope of practice of a licensed nurse. Delegating these tasks to an assistive personnel could potentially lead to misunderstandings, errors, or legal implications.
Question 4 of 5
A nurse is providing teaching to the partner of a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following pieces of information should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: "You should administer the medication immediately before bedtime." Donepezil is typically recommended to be taken at bedtime to reduce the risk of side effects such as nausea and insomnia. Administering it at this time also helps with adherence to the medication schedule.
Choice B is incorrect because donepezil does not cure Alzheimer's disease, so the dose is not decreased as the disease improves.
Choice C is incorrect because while donepezil may help with symptoms, it does not stop the progression of the disease.
Choice D is incorrect because donepezil does not decrease the risk of falls; in fact, it may cause side effects that increase the risk of falls.
Question 5 of 5
A nurse is caring for a client who is receiving end-of-life care. The client states, 'The nurses here don’t do a good job caring for me.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct response is D: "Can you tell me more about what is upsetting you?" This response demonstrates active listening and empathy, allowing the client to express their concerns and feelings. By encouraging open communication, the nurse can address the client's specific needs and provide appropriate support. This approach fosters trust and enhances the therapeutic relationship, leading to better end-of-life care.
Choices A, B, and C do not directly address the client's expressed dissatisfaction and may come across as dismissive or deflective.
Choice A shifts the focus to family dynamics, choice B generalizes the client's feelings, and choice C assumes the nurses' intentions without acknowledging the client's perspective.