ATI RN Mental Health 2023 Exam 2 | Nurselytic

Correct Answer: D

Rationale: The correct response is D: "You will need to have your blood drawn." This is because lithium is a medication that requires monitoring of blood levels to prevent toxicity. Lethargy, muscle weakness, and blurred vision are common signs of lithium toxicity. By regularly monitoring blood levels, the nurse can ensure the client is within the therapeutic range and adjust the dosage if needed.


Choice A is incorrect because the symptoms are indicative of toxicity and may not improve on their own.
Choice B is incorrect as continuing the medication without addressing the toxicity can worsen the client's condition.
Choice C is incorrect as decreasing sodium intake is not directly related to managing lithium toxicity.

Correct Answer: A

Rationale: The correct answer is A: Let's discuss what you feel embarrassed about. This response demonstrates active listening and empathy, encouraging the client to open up about their feelings without judgment. It shows support and willingness to help address the underlying issue.
Choice B is incorrect as it may pressure the client to disclose information prematurely.
Choice C is dismissive and does not validate the client's feelings.
Choice D generalizes and does not address the client's specific situation.

Correct Answer: C

Rationale: The correct answer is C: Provide environmental cues. Delirium can be triggered by environmental factors. Providing familiar cues, such as a clock or calendar, can help orient the client and decrease confusion, promoting safety. A: Promoting decision making may overwhelm the client. B: Discouraging visits can worsen feelings of disorientation. D: Physical restraints should be avoided as they can increase agitation and risk of injury.

Correct Answer: A

Rationale:
Correct Answer: A


Rationale: Statement A reflects countertransference as it indicates a personal connection between the nurse and the client based on the nurse's past experience with their brother. This can lead to biased care.
Summary:
- Statement B is focused on the client's responsibility.
- Statement C is about the client's behavior during therapy.
- Statement D is about the client's request for a date with the nurse, which is boundary crossing.

Correct Answer: C

Rationale: The correct answer is C: "I will place a sliding bolt lock just above the doorknob." This statement indicates an understanding of the teaching on home safety for a client with advanced Alzheimer's disease because it addresses the specific safety measure of installing a sliding bolt lock to prevent the client from wandering outside unsupervised. This type of lock is a practical strategy to enhance the client's safety by restricting access to potentially dangerous areas.


Choice A is incorrect because notifying law enforcement within 2 hours of the client not being found is not a preventative safety measure.
Choice B is incorrect as giving a photo to the police is reactive and may not prevent the client from wandering.
Choice D is incorrect as ensuring the bedroom is dark at night does not directly address the safety concern of wandering.