ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
Correct Answer: C
Rationale: The correct answer is C: The client's manifestations developed suddenly. Delirium is characterized by an acute onset of confusion, disorientation, and altered consciousness. The sudden development of symptoms differentiates delirium from other conditions like dementia.
Choices A and B do not specifically indicate delirium and could be seen in various mental health disorders.
Choice D suggests potential cognitive impairment, which could be present in delirium but is not a specific indicator.
Choices E, F, and G are irrelevant. In summary, the sudden onset of symptoms is a key feature that differentiates delirium from other conditions in this scenario.
Question 2 of 5
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Identify and schedule alternative group activities for the client. Group activities can provide social support and a sense of belonging, which are crucial for individuals with major depressive disorder. It can help reduce isolation and improve mood.
Choice B is incorrect as discouraging the client from expressing feelings of anger can hinder emotional expression and may worsen symptoms.
Choice C is incorrect as keeping a bright light on at night can disrupt sleep, which is often already affected in individuals with major depressive disorder.
Choice D is incorrect as physical activity during the day is beneficial, but it does not address the social and emotional needs that group activities can fulfill.
Question 3 of 5
A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?
Correct Answer: B
Rationale: The correct assessment the nurse should perform is B: Blood pressure. Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Monitoring the client's blood pressure is crucial to assess for any sudden increases that could indicate a potential crisis. Bowel sounds (choice
A), oxygen saturation (choice
C), and pupil response (choice
D) are not directly related to the potential side effect of consuming tyramine-rich foods.
Question 4 of 5
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Document the client's refusal of the treatment in the medical record. This is the appropriate action because it respects the client's autonomy and ensures that the refusal is properly documented for legal and ethical reasons. It also allows for further discussions with the client in the future.
Choice A is incorrect because the client's involuntary commitment does not negate their right to refuse treatment.
Choice C is incorrect as ECT does require informed consent.
Choice D is inappropriate as involving the client's family without the client's consent violates the client's privacy and autonomy.
Question 5 of 5
A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Recent head injury. This assessment finding should be reported to the provider because bupropion is contraindicated in individuals with a recent history of head injury or seizure disorder due to an increased risk of seizures. Reporting this information is crucial for the provider to make an informed decision regarding the safety and appropriateness of prescribing bupropion to the client.
Other choices are incorrect because:
A: Hypothyroidism - Hypothyroidism is not a contraindication for bupropion use.
B: Knee arthroplasty 1 month ago - Recent knee surgery is not directly related to the use of bupropion for smoking cessation.
C: Hepatitis B infection - Hepatitis B infection is not a contraindication for bupropion use.
In summary, the correct answer, recent head injury, is important to report due to the increased risk of seizures with bupropion use in individuals with this condition