ATI RN Mental Health 2023 Exam 3 | Nurselytic

Correct Answer: A,B

Rationale: Action to Take: A, B; Potential Condition: Sexual assault; Parameter to Monitor: D, E.

Rationale:
1. The nurse should review diagnostic results (Action
A) to identify any physical evidence of sexual assault.
2. Conducting an abdominal examination (Action
B) can reveal signs of trauma or injury related to sexual assault.
3. Sexual assault is the potential condition (
C) the nurse should consider based on the client's presentation.
4. Monitoring the client's temperature (Parameter
D) is important to detect any signs of infection or hypothermia post-assault.
5. Monitoring drug assessment (Parameter E) is crucial to assess for any substances or drugs involved in the assault.

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: A

Rationale: The correct answer is A: Hypertension. Cocaine is a stimulant drug that causes vasoconstriction and increases heart rate, leading to elevated blood pressure. This is due to the release of catecholamines like norepinephrine. Cocaine does not typically cause hypothermia or bradycardia. Hypothermia is more commonly associated with sedative overdose, and bradycardia is not a typical effect of stimulant drugs like cocaine.
Therefore, in a client who has recently used cocaine, the nurse should expect hypertension as a common clinical manifestation.

Correct Answer: B

Rationale: The correct answer is B: "I will use the coping mechanisms that helped me in the past." This response indicates understanding as it shows the client's awareness of their previous successful strategies for managing depressive symptoms. By recognizing the effectiveness of past coping mechanisms, the client demonstrates an understanding of self-care and the importance of utilizing proven strategies.
Summary of other choices:
A: "I will stay in bed on days when I feel exhausted." - This choice reflects a passive and potentially maladaptive behavior that may worsen depression symptoms.
C: "I will avoid talking about events that upset me." - Avoidance can lead to suppression of emotions and hinder the client's ability to address underlying issues.
D: "I will rely on my partner to plan out my schedule each day." - This choice indicates dependence on others rather than promoting self-reliance and self-care behaviors.

Correct Answer: C

Rationale: The correct answer is C: Keep conversations and activities to a minimum during the nighttime. This is the best action to address the client's concern of noise disrupting their sleep. By minimizing conversations and activities during nighttime, the nurse creates a quieter environment that can help the client sleep better. This approach respects the client's need for rest and promotes a therapeutic environment.

A: Incorrect. Telling the client they will get used to the noise minimizes their feelings and does not directly address the issue.
B: Incorrect. Recommending the client to sleep during the day does not address the client's need to sleep at night.
D: Incorrect. Turning on the client's television may not necessarily address the environmental noise issue and may not be conducive to a restful sleep.