ATI RN Mental Health 2023 III

Extract:

Question 1 of 5

A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?

A. You will need to have your blood drawn. B. These symptoms will improve over time. C. You should decrease your intake of sodium. D. Continue the medication as prescribed.

Correct Answer: A

Rationale: Rationale for
Choice A (Correct Answer): The nurse should advise the client to have their blood drawn because the symptoms of lethargy, muscle weakness, and blurred vision could indicate lithium toxicity. Regular monitoring of lithium levels through blood tests is crucial to prevent toxicity and ensure the client's safety.

Summary of Other

Choices:
B: These symptoms will not necessarily improve over time as they could be indicative of lithium toxicity.
C: Decreasing sodium intake is not directly related to managing lithium toxicity symptoms.
D: Continuing the medication without addressing the symptoms of toxicity can lead to further complications.
E, F, G: No information provided for these choices.

Question 2 of 5

A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?

A. Keep the restraints on for a minimum of 1 hour B. Monitor the child's vital signs every 15 minutes C. Ask the provider to renew the prescription for the restraints every 24 hours D. Arrange an in-person evaluation by the child's provider within 2 hours of initiating restraints

Correct Answer: B

Rationale: The correct answer is B: Monitor the child's vital signs every 15 minutes. This action is essential to ensure the child's safety while in restraints. Monitoring vital signs helps the nurse assess the child's physiological response to the restraints, such as changes in heart rate, blood pressure, and respiratory rate. This allows for early detection of any complications or distress, enabling prompt intervention if necessary. It is crucial to closely monitor vital signs in this situation to prevent any adverse outcomes related to the use of physical restraints. Keeping the restraints on for a minimum of 1 hour (
A) is not appropriate as the duration should be based on the child's behavior and safety. Asking the provider to renew the prescription for the restraints every 24 hours (
C) is important but not the immediate priority. Arranging an in-person evaluation by the child's provider within 2 hours of initiating restraints (
D) is also important, but monitoring vital signs is the more immediate and critical action

Question 3 of 5

A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

A. Participate in solitary activities with a client who has mania B. Discuss adverse effects of antianxiety medications with a client who has anxiety disorder C. Witness an informed consent for a client who is scheduled for electroconvulsive therapy D. Explain the benefits of light therapy with a client who has depressive disorder

Correct Answer: A

Rationale: The correct answer is A: Participate in solitary activities with a client who has mania. Assistive personnel can engage in activities that provide social interaction and support for clients with mania. This task does not require specialized nursing knowledge or assessment skills. The other choices involve providing education, obtaining consent, or explaining treatment modalities, which should be done by a licensed nurse due to the complexity and potential risks involved. It is important to delegate tasks that align with the assistive personnel's scope of practice and level of training to ensure safe and effective client care.

Question 4 of 5

A nurse is receiving change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?

A. A client who has narcissistic personality disorder B. A client who has mild anxiety disorder C. A client who has severe obsessive-compulsive disorder D. A client who has conversion disorder

Correct Answer: D

Rationale: The correct answer is D because clients with conversion disorder may present with sensory impairments, such as blindness or paralysis, without a clear medical cause. The nurse should assess for these impairments to provide appropriate care.

Choices A, B, and C do not necessarily require specific assessments related to sensory impairments.
Choice A is associated with self-centeredness, choice B with excessive worry, and choice C with compulsive behaviors.
Therefore, the nurse should focus on assessing client D for sensory impairments to address their unique needs.

Question 5 of 5

A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?

A. Encourage the client to express their feelings B. Share personal stories of grief with the client C. Provide the client with a timeline for grieving D. Show sympathy for the client when discussing their condition

Correct Answer: A

Rationale: The correct answer is A: Encourage the client to express their feelings. This is crucial because allowing the client to talk about their emotions can help them process their grief and feel supported. Sharing personal stories (
B) may not be appropriate as it shifts the focus from the client. Providing a timeline (
C) for grieving is not effective as everyone grieves differently. Showing sympathy (
D) is important, but encouraging expression of feelings is more proactive in supporting the client.

ATI RN Mental Health 2023 III | Nurselytic

Nurselytic

ATI RN

ATI RN