ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?
Correct Answer: A
Rationale: Dialectical behavior therapy is specifically designed to address self-harm and emotional dysregulation in borderline personality disorder.
Question 2 of 5
A nurse is assessing a client who has a history of substance use disorder and states,"People are out to get me. The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
Correct Answer: D
Rationale: Cocaine toxicity is the most likely cause of the client's symptoms. Cocaine can lead to paranoia tachycardia and hypertension. The combination of these symptoms suggests acute cocaine toxicity making it the priority concern for the nurse. Prompt intervention is necessary to address the potential life-threatening effects of cocaine toxicity.
Question 3 of 5
A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states,I feel unmotivated and don't feel like leaving my home. Which of the following recommendations should the nurse make to address the client's social isolation?
Correct Answer: D
Rationale: Joining a low-impact exercise class promotes physical activity,social interaction and routine which can help combat social isolation and improve mood in depression.
Question 4 of 5
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?
Correct Answer: A
Rationale: Assisting with ambulation is within assistive personnel's scope ensuring safety post-procedure under supervision.
Question 5 of 5
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: D
Rationale: Sore throat is a priority finding for the nurse to report to the provider. Sore throat is a sign of infection,inflammation or irritation of the throat which can be caused by various factors such as viruses bacteria allergens or irritants. However,in a client who is taking clozapine sore throat can also indicate a serious and potentially fatal adverse effect of the medication: severe neutropenia. Neutropenia is a condition in which the number of neutrophils a type of white blood cell that fights infection is abnormally low. This increases the risk of developing serious and life-threatening infections especially in the mouth throat and respiratory tract. Clozapine can cause neutropenia in some patients especially during the first 18 weeks of treatment and it is the most common reason for discontinuing the medication.
Therefore any client who is taking clozapine and develops a sore throat should be evaluated by the provider as soon as possible to rule out neutropenia and initiate appropriate treatment if needed. The nurse should also educate the client on the importance of regular blood tests to monitor the absolute neutrophil count (AN
C) and the signs and symptoms of infection such as fever chills weakness or sore throat. The nurse should also instruct the client to avoid contact with people who are sick practice good hygiene and report any signs of infection immediately.