ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?
Correct Answer: A
Rationale: Alprazolam rapidly reduces acute panic symptoms providing immediate relief during an attack.
Question 3 of 5
A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,B,E
Rationale: BLanugo bradycardia and Russell's sign are common in anorexia due to malnutrition and purging behaviors.
Question 4 of 5
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Post-meal monitoring prevents binge episodes addressing core behaviors of the disorder.
Question 5 of 5
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Documenting refusal respects autonomy and informs the care team maintaining ethical standards.