ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?
Correct Answer: A
Rationale: Haloperidol can cause QT prolongation, increasing the risk of dysrhythmias.
Question 2 of 5
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?
Correct Answer: C
Rationale: The correct answer is C: The client has lost 30 lb. This indicates maladaptive grieving as significant weight loss is a common physical manifestation of unresolved grief. The weight loss could be due to lack of appetite or neglecting self-care, both of which are concerning signs. Losing a large amount of weight within a short period can negatively impact the client's health and well-being.
Choices A, B, and D are not directly related to maladaptive grieving. Age (
A) and the time since the husband's death (
B) are not indicative of maladaptive grieving, as everyone grieves differently and at their own pace. Difficulty sleeping (
D) is a common symptom of grief but may not necessarily indicate maladaptive grieving on its own.
Question 3 of 5
A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: "What is it about the adverse effects that concern you?" This response demonstrates active listening and empathy, allowing the nurse to understand the specific concerns of the client and address them effectively. By asking this question, the nurse can provide tailored information and support, helping to alleviate the client's worries.
Other choices are incorrect:
A: This response does not address the client's concerns directly and may not provide the immediate support needed.
B: While support from organizations like the American Cancer Society is valuable, it does not address the client's concerns at that moment.
D: This response dismisses the client's worries and does not offer reassurance or support. It can also instill fear and anxiety in the client.
Question 4 of 5
A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?
Correct Answer: D
Rationale: The correct answer is D: Safety plan. For a client with borderline personality disorder, a safety plan is crucial to address self-harm behaviors or suicidal ideation. It involves identifying triggers, warning signs, coping strategies, and emergency contacts to prevent harm. Dialectical behavior therapy (
A) is a recommended treatment, but it's not specifically for discharge planning. Behavioral contract (
B) may lack the flexibility needed for managing impulsive behaviors in BPD. Milieu therapy (
C) focuses on therapeutic environment, not individual discharge planning. Other choices are omitted as they are not relevant to the specific needs of a client with borderline personality disorder.
Question 5 of 5
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). NMS is a rare but life-threatening side effect of antipsychotic medications like haloperidol. The client's symptoms of high fever, elevated blood pressure, and muscle rigidity are classic signs of NMS. The nurse should suspect NMS due to the acute onset of these symptoms in a client taking haloperidol.
A) Agranulocytosis is a potential side effect of antipsychotic medications but does not present with the same symptoms as NMS.
B) Akathisia is characterized by restlessness and does not typically involve fever or muscle rigidity.
C) Tardive dyskinesia is a movement disorder that develops with long-term antipsychotic use and does not present acutely with fever and elevated blood pressure.
Therefore, the correct choice is D as it aligns with the client's presentation and medication history.