ATI RN
ATI NURS 4850 Mental Health Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has schizophrenia and tells the nurse,“They lie about me all the time and they are trying to poison my food.” Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without validating the delusions. It shows empathy and understanding without challenging the client's beliefs.
Choice A asks for specific details that may reinforce the delusions.
Choice C denies the client's reality, which can damage the therapeutic relationship.
Choice D encourages the client to explain their delusions, potentially reinforcing them.
Question 2 of 5
A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Apply bilateral wrist restraints. After cleft palate repair, the toddler should not be allowed to touch or manipulate the surgical site to prevent disruption of sutures or injury. Wrist restraints are necessary to ensure the toddler's safety and promote optimal healing. Administering opioids for pain (
A) is important but not the priority in this scenario. Implementing a soft diet (
C) and offering fluids through a straw (
D) are appropriate postoperative care but do not address the risk of injury to the surgical site.
Question 3 of 5
A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Restlessness. Opioid withdrawal typically presents with symptoms such as restlessness, anxiety, agitation, insomnia, and irritability. This is due to the body's dependence on opioids and the sudden absence of the drug. Bradycardia (
A), constipation (
B), and hypotension (
C) are actually common side effects of opioid use, not withdrawal.
Therefore, they would not be expected manifestations during opioid withdrawal.
Question 4 of 5
A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture. Which one of the following should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. This is done to provide local anesthesia and reduce pain during the lumbar puncture. The cream numbs the skin, making the procedure less uncomfortable for the infant.
A: Placing the infant in an infant seat is not necessary following a lumbar puncture.
B: Holding the infant's chin to his chest and knees to his abdomen during the procedure may not be appropriate and could interfere with the procedure.
C: Keeping the infant NPO for 6 hours prior to the procedure is not necessary for a lumbar puncture.
In summary, the correct answer, D, is essential for providing comfort and reducing pain during the procedure, while the other options are not relevant to the care of the infant during a lumbar puncture.
Question 5 of 5
A nurse is caring for a client who has schizophrenia and tells the nurse,“They lie about me all the time and they are trying to poison my food.” Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without validating the delusions. It shows empathy and understanding without challenging the client's beliefs.
Choice A asks for specific details that may reinforce the delusions.
Choice C denies the client's reality, which can damage the therapeutic relationship.
Choice D encourages the client to explain their delusions, potentially reinforcing them.