ATI RN Mental Health 2023 Exam 3

Extract:

Question 1 of 5

A nurse is caring for a client who has bulimia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

A. Monitor the client's bathroom trips. B. Allow the client's family to bring the client food. C. Allow the client to create their own meal schedule. D. Encourage the client to exercise frequently.

Correct Answer: A

Rationale: The correct answer is A: Monitor the client's bathroom trips. This is crucial in managing bulimia nervosa as it helps assess potential purging behavior, which is common in individuals with this disorder. Monitoring bathroom trips allows the nurse to intervene promptly if the client engages in harmful behaviors like self-induced vomiting.

Choice B is incorrect because allowing the family to bring food may enable the client's disordered eating patterns.
Choice C is incorrect as clients with bulimia nervosa often struggle with creating healthy meal schedules, so guidance from healthcare professionals is essential.
Choice D is incorrect because excessive exercise can contribute to the maintenance of the disorder.

Question 2 of 5

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

A. The client demonstrates that he is oriented to person, place, and time. B. The client refuses to take his medication unless he is released. C. The client states that he will harm himself unless the restraints are removed. D. The client is able to follow commands.

Correct Answer: D

Rationale: The correct answer is D. When the client is able to follow commands, it indicates that they have regained control and are not a danger to themselves or others. This criterion ensures the safe removal of physical restraints.
Choice A is incorrect as orientation alone does not guarantee the client's safety.
Choice B is incorrect because medication refusal does not necessarily indicate safety.
Choice C is incorrect as the client's verbal threat of harm is not a reliable indicator of their actual intentions.

Question 3 of 5

A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

A. Why do you think this has happened?' B. Are you okay with not being able to do some things you used to do?' C. Is anyone available to assist you with your hygiene?' D. How has this impacted your life?'

Correct Answer: D

Rationale: The correct answer is D: "How has this impacted your life?" This question helps assess the client's emotional response and coping mechanisms towards the stroke. By understanding the impact, the nurse can tailor support and interventions accordingly.
Choice A focuses on causation rather than coping.
Choice B assumes the client is not okay with limitations.
Choice C addresses practical assistance, not coping.

Question 4 of 5

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A. Place the client in a reclining chair. B. Install sensor devices on outside doors. C. Position the mattress on the floor. D. Encourage physical activity prior to bedtime. E. Put locks at the top of doors.

Correct Answer: B,C,E

Rationale:
Correct
Answer: B, C, E

Rationale:
B: Installing sensor devices on outside doors will alert the caregiver if the client tries to wander at night, preventing falls and ensuring safety.
C: Positioning the mattress on the floor reduces the risk of injury if the client falls out of bed during the night.
E: Putting locks at the top of doors can prevent the client from wandering outside at night, reducing the risk of falls and injuries.

Incorrect

Choices:
A: Placing the client in a reclining chair may not address the wandering issue and could lead to discomfort or pressure ulcers.
D: Encouraging physical activity prior to bedtime may increase restlessness and agitation, potentially worsening the wandering behavior.
Other options are not provided, but it's important for the caregiver to maintain a safe environment and provide appropriate supervision for the client.

Question 5 of 5

A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

A. Writes a detailed daily activity schedule B. Refuses to engage in conversation C. Isolates self from others D. Reports a lack of sleep

Correct Answer: D

Rationale:
Correct
Answer: D - Reports a lack of sleep

Rationale:
1. Lack of sleep is a hallmark symptom of acute mania in bipolar disorder.
2. During acute mania, individuals often experience reduced need for sleep or insomnia.
3. This symptom can lead to increased energy levels, impulsivity, and agitation.
4. The nurse should prioritize addressing the client's sleep disturbance to prevent exacerbation of manic symptoms.

Other

Choices:
A: Writing a detailed daily activity schedule is not necessarily indicative of acute mania. It could be a coping mechanism or part of a structured routine.
B: Refusing to engage in conversation may suggest social withdrawal, but it is not specific to acute mania.
C: Isolating oneself from others can be a sign of depression or anxiety, but it does not directly indicate acute mania.

ATI RN Mental Health 2023 Exam 3 | Nurselytic

Nurselytic

ATI RN

ATI RN