ATI Mental Health Practice B 2023

Correct Answer: B

Rationale: The correct answer is B: Remain with the client for a while. This is the most therapeutic action as it provides immediate emotional support and reassurance to the client experiencing panic-level anxiety. By staying with the client, the nurse can help establish a sense of safety and trust, which is crucial in managing acute anxiety. Additionally, the nurse can observe the client's behavior closely for any signs of escalating distress and intervene promptly if needed.



Choices A, C, and D are incorrect:
A: Suggesting that the client rest in bed may not address the client's emotional needs or provide the necessary support during a panic attack.
C: Medicating the client with a sedative should be done based on a physician's order and after a thorough assessment. It is not the initial therapeutic response in this situation.
D: Having the client join a therapy group may be overwhelming and inappropriate during an acute panic attack. Individual support is more appropriate in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer diazepam. This is the first action the nurse should take because delirium tremens is a severe form of alcohol withdrawal that can lead to life-threatening complications such as seizures and hallucinations. Diazepam is a benzodiazepine medication that helps to control the symptoms of alcohol withdrawal by calming the central nervous system. Administering diazepam promptly can prevent the client from experiencing severe symptoms and reduce the risk of complications.

Raising the side rails of the bed (
B) may be important for safety but is not the first priority in managing delirium tremens. Obtaining a medical history (
C) is important for overall assessment but is not the immediate action needed in this critical situation. Starting intravenous fluids (
D) may be necessary to maintain hydration but does not address the urgent need to manage the symptoms of delirium tremens.

Correct Answer: B, D, E

Rationale: Tardive dyskinesia involves involuntary repetitive movements such as lip smacking, facial grimacing, and pelvic rocking.

Correct Answer: D

Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). NMS is a rare but life-threatening side effect of antipsychotic medications like haloperidol. The client's symptoms of high fever, elevated blood pressure, and muscle rigidity are classic signs of NMS. The nurse should suspect NMS due to the acute onset of these symptoms in a client taking haloperidol.
A) Agranulocytosis is a potential side effect of antipsychotic medications but does not present with the same symptoms as NMS.
B) Akathisia is characterized by restlessness and does not typically involve fever or muscle rigidity.
C) Tardive dyskinesia is a movement disorder that develops with long-term antipsychotic use and does not present acutely with fever and elevated blood pressure.
Therefore, the correct choice is D as it aligns with the client's presentation and medication history.

Correct Answer: A

Rationale: Reflecting the client’s feelings validates emotions and encourages further expression.