ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has bipolar disorder. Which of the following is the priority for the nurse to assess during a manic episode?
Correct Answer: A
Rationale: The correct answer is A: Sleep pattern. During a manic episode in bipolar disorder, lack of sleep can exacerbate symptoms and lead to further instability. Assessing the client's sleep pattern is crucial as it directly impacts their mental health and overall well-being. It is essential to prioritize addressing sleep disturbances to prevent escalation of manic symptoms.
Choices B, C, and D are important aspects of overall health but assessing sleep pattern takes precedence during a manic episode due to its significant impact on the client's condition.
Question 2 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 3 of 5
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Notify the client about designated times for meals. This intervention is important for clients with anorexia nervosa to establish a structured eating routine, prevent skipping meals, and promote regular eating habits. By notifying the client about designated times for meals, the nurse helps the client maintain a consistent and balanced diet, which is crucial for the treatment of anorexia nervosa. Weighing the client weekly (
A) may lead to increased anxiety and obsession with weight. Negotiating weight gain (
C) could reinforce unhealthy behaviors. Decreasing fiber intake (
D) is not a recommended intervention as it may compromise the client's nutritional intake.
Question 4 of 5
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. During alcohol withdrawal, the body may experience autonomic dysregulation leading to increased body temperature. This can be a sign of severe withdrawal and requires immediate attention. Hyperglycemia (
A) is not typically associated with alcohol withdrawal. Decreased blood pressure (
B) and heart rate (
C) are more commonly seen in alcohol withdrawal as a result of the depressant effects of alcohol on the central nervous system.
Question 5 of 5
A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Establish a rapport to foster trust. This should be the first action as building a therapeutic relationship with the client is crucial for effective care. Trust is essential for the client to open up and engage in treatment. Continuous one-to-one observation (
A) may be necessary but establishing trust comes first. Asking the client to sign a no-suicide contract (
B) is important but should come after establishing rapport. Encouraging participation in group therapy (
C) may be beneficial but not the initial priority.