ATI RN
ATI nsg 133 Mental Health Exam 2 Questions
Extract:
Question 1 of 5
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates that the teaching was effective?
Correct Answer: B
Rationale:
Correct
Answer: B: I will develop a decreased physical response to alcohol.
Rationale: Alcohol tolerance refers to the body's reduced response to the effects of alcohol over time. When a person develops alcohol tolerance, they require more alcohol to achieve the same effects as before, leading to a decreased physical response to alcohol. This statement indicates an understanding of the concept of alcohol tolerance.
Incorrect
Choices:
A: Alcohol tolerance causing an increased effect when taking opiates is incorrect as alcohol tolerance does not directly affect the effects of opiates.
C: Alcohol tolerance developing as a medical emergency due to withdrawal is incorrect as alcohol tolerance is a gradual process, not an acute emergency.
D: Alcohol tolerance producing physical changes when not recently ingesting alcohol is incorrect as the effects of alcohol tolerance are seen when alcohol is consumed regularly, not when it is not consumed.
Question 2 of 5
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Remove any objects from the client's environment that could be used for self-harm. This is the priority because it directly addresses the immediate risk of self-harm, which is crucial in ensuring the client's safety. By removing objects that could be used for self-harm, the nurse reduces the client's access to means of carrying out suicidal thoughts. This action helps prevent impulsive acts and provides a safer environment for the client.
A: Locking doors and securing windows may be necessary in certain situations, but it does not address the immediate risk of self-harm.
C: Providing plastic eating utensils is not relevant to the client's safety in this context.
D: Assigning a staff member to stay with the client is important for supervision but does not directly address the removal of harmful objects.
Question 3 of 5
A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)
Correct Answer: A,BC,D,E
Rationale: The correct choices for priority risk assessment for a client with acute alcohol intoxication are A, B, C, D, and E.
A: Risk for aspiration is crucial due to impaired gag reflex, leading to the potential for choking on vomit.
B: Impaired coordination and judgment can result in accidents and injuries.
C: Alcohol toxicity can affect liver function, leading to complications.
D: Dizziness and unsteady gait increase the risk of falls and related injuries.
E: Alcohol impairs immune function, increasing the risk of infections.
Other choices are less immediate concerns or not directly related to the acute effects of alcohol intoxication, making them lower priority for assessment in this scenario.
Question 4 of 5
A nurse is caring for a patient with a history of sedative use disorder. Which cue is indicative that a client has used a sedative-hypnotic drug?
Correct Answer: C
Rationale: The correct answer is C: Excessive drowsiness and sedation. Sedative-hypnotic drugs depress the central nervous system, leading to drowsiness and sedation. The excessive drowsiness is a key cue indicating the use of sedative-hypnotic drugs. Elevated blood pressure and heart rate (
A) are more common with stimulant use. Increased energy and hyperactivity (
B) are opposite effects of sedatives. Improved sleep quality and duration (
D) are expected with sedative use, not indicative of drug use.
Question 5 of 5
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale: Planning the client's schedule to allow time for rituals is the most appropriate action for a client with OCD as it acknowledges the client's need to engage in compulsive behaviors while also maintaining structure. Allowing time for rituals can help reduce anxiety and provide a sense of control for the client. Isolating the client (
A) may increase distress and worsen symptoms. Setting strict limits (
C) may lead to resistance and escalation of behaviors. Confronting the client (
D) can be perceived as invalidating and may increase anxiety.