ATI RN Mental Health 2023 Exam 2 | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: "Have you noticed an increase in thirst?" This question is relevant because olanzapine, an antipsychotic medication, can cause side effects like increased thirst due to its impact on the body's regulation of water balance. By asking this question, the nurse can assess for potential side effects of the medication and monitor for dehydration.

Choices A, B, and D are less relevant as they do not directly relate to common side effects of olanzapine.
Choice A about decreased taste is not a common side effect of olanzapine.
Choice B about ringing in the ears is more likely related to ototoxic medications.
Choice D about unintentional weight loss is not a common side effect of olanzapine, which is more commonly associated with weight gain.

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: The client is constantly talking. In bipolar disorder, during the manic phase, individuals often exhibit rapid speech, impulsivity, and excessive talking. This behavior is a hallmark of mania. The other choices are incorrect because expressing feelings of inferiority (
B) is more indicative of depression, memory loss (
C) could be a symptom of various conditions but not specific to mania, and sleeping over 10 hours a day (
D) is more characteristic of depression or sedation from medication.

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 current stage of grief allows the nurse to tailor interventions accordingly. By assessing the client's stage, the nurse can provide targeted support and interventions to help the client process and cope with their grief effectively.


Choice B is incorrect because while informing the client about expected feelings is important, it is not the priority over assessing the current stage of grief.
Choice C is incorrect as physical activities may not be suitable or helpful depending on the client's stage of grief.
Choice D is also incorrect as discussing the use of a spiritual grief counselor should come after assessing the client's current needs and preferences.

Correct Answer: C

Rationale: The correct answer is C: Obtain a prescription for seclusion within 30 minutes. This action is crucial as seclusion should only be implemented with a physician's order to ensure the client's safety and rights are protected. The nurse must promptly obtain this order to ensure the client's needs are met in a timely manner.


Choice A is incorrect because documenting the client's behavior every 60 minutes does not address the immediate need for a physician's order for seclusion.
Choice B is incorrect as there is no specific time limit for seclusion, and it should only be ended with a physician's approval.
Choice D is incorrect as monitoring vital signs every 4 hours is important but not as urgent as obtaining the seclusion prescription.