ATI RN Mental Health 2023 III | Nurselytic

Correct Answer: D, E

Rationale:
Correct Answer: D, E


Rationale:
1. Talking to the client using short, simple sentences helps in calming the client down as complex information may escalate the situation.
2. Identifying the client's stressors allows the nurse to address the underlying causes of the behavior and provide appropriate support.
Summary:
A: Speaking loudly can escalate the situation further.
B: Standing directly in front may be perceived as confrontational, worsening the behavior.
C: Involving security guards may increase agitation and escalate the situation.
D: Talking using short, simple sentences can help de-escalate and communicate effectively.
E: Identifying stressors helps address root causes and provide appropriate support.

Correct Answer: B

Rationale: The correct answer is B: Explain to the client that the duration of grief is highly variable and can last for years. This is the most appropriate action because it acknowledges the client's feelings of depression and grief as valid and normal following the death of a loved one. By explaining the variability in the duration of grief, the nurse provides reassurance and validation to the client's experience. This approach helps in normalizing the client's emotions and promotes a sense of understanding and acceptance.

Choice A is incorrect because recommending solitary activities may worsen the client's depression by isolating them.
Choice C is incorrect as encouraging avoidance of discussing the death can hinder the client's grieving process.
Choice D is incorrect as cautioning against feeling angry can invalidate the client's emotions.

Correct Answer: A

Rationale: The correct answer is A: Offer the client the medication at the next scheduled dose time. This option respects the client's autonomy and right to refuse treatment, while also ensuring that the client receives the necessary medication. By offering the medication at the next scheduled time, the nurse can continue to monitor the client's condition and provide support without resorting to coercive measures.

Option B: Implement consequences until the client takes the medication, is incorrect as it goes against the client's right to refuse treatment and may damage the therapeutic relationship.

Option C: Inform the client that he does not have the right to refuse the medication, is incorrect as it disregards the client's autonomy and can lead to further resistance to treatment.

Option D: Administer the medication to the client via IM injection, is incorrect as it violates the client's right to make informed decisions about their treatment. This approach should only be considered in emergency situations where the client's safety is at risk.

Correct Answer: A

Rationale: The correct answer is A: Establish confidentiality guidelines with the client. This is the first action the nurse should take to build trust and establish a therapeutic relationship. Confidentiality is crucial in mental health care to ensure clients feel safe sharing personal information. Sharing information about the disorder (choice
B) may be important but should come after confidentiality is established. Assisting the client with coping strategies (choice
C) and helping them make behavioral changes (choice
D) are interventions that can be implemented once a trusting relationship is in place.

Correct Answer: B

Rationale: The correct answer is B: Chlordiazepoxide. During acute alcohol withdrawal, chlordiazepoxide, a benzodiazepine, is commonly prescribed to manage symptoms such as anxiety, tremors, and seizures by acting on GABA receptors to reduce CNS excitability. Disulfiram (
A) is used for alcohol aversion therapy and can cause a severe adverse reaction if alcohol is consumed. Buprenorphine (
C) is used for opioid addiction, not alcohol withdrawal. Bupropion (
D) is an antidepressant and smoking cessation aid, not indicated for alcohol withdrawal.