ATI RN Mental health 2019 NGN II | Nurselytic

Correct Answer: B

Rationale: The correct answer is B: Decrease the number of verbal outbursts. This goal is appropriate for a client with antisocial personality disorder as it focuses on managing impulsive behavior, which is a common symptom of the disorder. Verbal outbursts can be disruptive and harmful to relationships. By setting a goal to decrease these outbursts, the client can work on improving their communication skills and impulse control.


Choice A is incorrect as using projection is not a recommended coping mechanism for individuals with antisocial personality disorder.
Choice C is not the most immediate concern and increasing self-esteem may not directly address the problematic behaviors associated with the disorder.
Choice D is also incorrect as using bargaining skills for behavioral consequences may not be effective in addressing the impulsive nature of the client's behavior.

Correct Answer: C

Rationale: The correct answer is C: The adolescent daughter who attempts to dominate the discussion. This behavior is indicative of monopolizing, where one family member dominates conversation or decision-making, limiting the participation of others. This can hinder effective communication and lead to imbalance in the family dynamic. In this scenario, the nurse should address the daughter's behavior to promote healthy dialogue and involvement of all family members.

A: The father intervening in arguments can be seen as mediation rather than monopolizing.
B: The mother expressing hostility is unrelated to monopolizing behavior.
D: The son's refusal to share personal feelings does not necessarily indicate monopolizing behavior.

Correct Answer: C

Rationale: The correct answer is C: Insomnia. Antidepressants often affect sleep patterns, leading to difficulty falling or staying asleep. This is a common side effect due to the medications' impact on neurotransmitters in the brain. Increased appetite (
A) is usually associated with certain antidepressants, but insomnia is more commonly linked. Hypertension (
B) is not a typical side effect of antidepressants, as they generally do not directly affect blood pressure. Excessive energy (
D) is not a common side effect of most antidepressants; in fact, they may initially cause fatigue or lethargy.

Correct Answer: B

Rationale:
Correct Answer: B. Having the provider assess the client within 1 hr after applying the restraints is the most appropriate action. This is crucial to ensure the client's safety, assess the need for continued restraint, and address any potential physical or emotional harm caused by the restraints. This prompt assessment can guide further care planning and interventions.

Incorrect

Choices:
A: Requesting prescription renewal every 8 hr is unnecessary and may not address the immediate need for assessment.
C: Hourly evaluation is important, but having the provider assess the client promptly is more critical for timely intervention.
D: Obtaining a prescription on an as-needed basis may delay necessary assessment and intervention, risking the client's safety.

Correct Answer: A

Rationale: The correct answer is A: Stop the newly licensed nurse from administering the medication. This is the first action the nurse manager should take as the client is refusing the medication and is in a manic state, which may affect their decision-making capacity. It is important to prioritize the client's autonomy and safety by ensuring that the medication is not administered against their will. Assessing for physical restraints (
B) should not be the first step as it may escalate the situation and compromise the client's dignity. Demonstrating verbal de-escalation techniques (
C) and discussing the purpose of the medication with the client (
D) are important interventions but should come after ensuring the immediate safety of the client by stopping the medication administration.