ATI RN Mental Health 2023 with NGN | Nurselytic

Correct Answer: B

Rationale: The correct answer is B: "Have you noticed an increase in thirst?" This question is relevant because olanzapine can cause side effects such as increased thirst and dry mouth due to its anticholinergic properties. The nurse should ask about thirst to monitor for potential dehydration or other related issues.

Choices A, C, and D are incorrect because they are not commonly associated with olanzapine use. Decreased taste (
A) is not a typical side effect, unintentional weight loss (
C) is less likely with olanzapine which is known to cause weight gain, and ringing in the ears (
D) is not a common side effect of this medication.

Correct Answer: A,B

Rationale:
Correct Answer: A, B


Rationale:
A: Identifying the client's stressors helps address the root cause of the behavior and provides insight into how to support the client effectively.
B: Talking to the client using short, simple sentences can help de-escalate the situation by promoting clear communication and reducing confusion.

Incorrect

Choices:
C: Speaking to the client in a loud voice can escalate the situation further, increasing agitation and distress.
D: Requesting security guards to restrain the client should be a last resort as it can lead to physical harm and worsen the client's emotional state.
E: Standing directly in front of the client can be perceived as confrontational and may increase the client's feelings of being trapped or threatened.

Correct Answer: A

Rationale: The correct answer is A: Identify the client's current stage of grief. This is the priority because understanding the client's stage of grieving will guide the nurse in providing appropriate interventions and support. By identifying the stage, the nurse can tailor the care plan to address specific needs and challenges the client may be facing. Understanding where the client is in the grieving process will also help in assessing the client's coping mechanisms and potential risks. Encouraging physical activities (
B) may be beneficial but not as crucial as understanding the client's current stage of grief. Discussing the use of a spiritual grief counselor (
C) or informing the client about expected feelings of anger (
D) are important interventions but should come after identifying the client's stage of grief.

Correct Answer: A

Rationale: The correct answer is A: Ask the client what they are hearing. This is the first action the nurse should take to assess the nature and content of the auditory hallucinations. Understanding the hallucinations will help the nurse determine the level of distress the client is experiencing and develop an appropriate care plan.


Choice B: Focusing on reality-based topics may be helpful but should come after assessing the hallucinations to establish rapport and trust with the client.


Choice C: Taking the client for a walk outside may not address the immediate concern of the auditory hallucinations and may not be appropriate without first understanding the hallucinations.


Choice D: Encouraging the client to listen to music may not be helpful if the auditory hallucinations are distressing and could potentially exacerbate the symptoms.

Correct Answer: A, B, D, E

Rationale:
Correct Answer: A, B, D, E


Rationale:
A: Vital signs - Monitoring vital signs helps assess the client's physiological response to treatment. Stable vital signs indicate progress.
B: Movement through stages of grief - Progression through grief stages signifies emotional healing and adaptation to treatment.
D: Participation in group therapy - Active participation in therapy shows engagement and willingness to work on recovery.
E: Appetite - Improved appetite suggests physical improvement and response to treatment.

Incorrect

Choices:
C: Cognition - Although important, cognition alone may not always directly indicate progress in response to treatment.
F: The client resolves to limit alcohol consumption - While important for health, this choice does not directly reflect progress in response to treatment.