ATI RN Mental Health 2023 with NGN | Nurselytic

Correct Answer: B

Rationale: The correct answer is B: Offer the client the medication at the next scheduled dose time. This option respects the client's right to refuse treatment while also ensuring that the medication is still available for when the client may choose to take it. Administering the medication via IM injection without the client's consent (
Choice
A) violates the client's autonomy and right to refuse treatment. Informing the client that they do not have the right to refuse the medication (
Choice
C) is unethical and goes against the client's rights. Implementing consequences until the client takes the medication (
Choice
D) is coercive and does not promote a therapeutic relationship. Overall, choice B respects the client's autonomy while still ensuring the medication is available for when the client is ready to take it.

Correct Answer: A

Rationale: The correct answer is A: Blood pressure. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause hypertensive crisis if combined with foods high in tyramine, like cheese and bananas. Assessing blood pressure first is critical to monitor for any signs of hypertensive crisis, such as a sudden increase in blood pressure that could lead to serious complications. Respiration, pulse, and temperature are also important to assess, but blood pressure takes precedence in this situation due to the potential life-threatening effects of hypertensive crisis.

Correct Answer: A

Rationale: The correct answer is A. A client with mania often exhibits rapid and excessive talking, a common symptom of mania. This behavior is known as pressured speech. Option B, memory loss, is not typically associated with mania but may occur in certain situations. Option C, sleeping over 10 hours a day, is more indicative of depression rather than mania. Option D, expressing feelings of inferiority, is more aligned with symptoms of depression, not mania.

Correct Answer: C

Rationale: The correct answer is C: Keep a sleep diary to promote a consistent sleep schedule. This intervention is appropriate because it helps the client track their sleep patterns, identify any disruptions, and establish a routine for better sleep hygiene. By maintaining a sleep diary, the client and the nurse can pinpoint factors contributing to the sleep disturbances and work together to develop a plan to address them. This intervention focuses on addressing the underlying issue of inconsistent sleep patterns, which can be crucial in managing depressive symptoms.

Option A (Take a 1-hour nap every day) may not be the best choice as it could potentially further disrupt the client's sleep pattern and lead to difficulties falling asleep at night. Option B (Exercise late in the day, preferably before bedtime) may also not be ideal as exercising close to bedtime can actually stimulate the body and make it harder to fall asleep. Option D (Discontinue any medication until your sleep disruption is addressed) is inappropriate as abruptly stopping medication can have negative consequences and should only be done

Correct Answer: A

Rationale:
Correct Answer: A

Rationale: The nurse should prioritize the client's comfort and autonomy. By acknowledging the client's discomfort with massage therapy, the nurse shows respect for the client's preferences and can explore alternative treatment options with the provider. This response promotes client-centered care.
Summary of Other

Choices:
B: This response does not address the client's underlying discomfort with touch and may not adequately address the client's needs.
C: While exploring the client's reasons for not liking touch is important, it does not directly address the immediate issue of the client's preference for a different treatment.
D: Dismissing the client's concerns and suggesting that the anxiety will lessen once the massage begins is not respectful of the client's feelings and may increase their distress.