ATI RN
ATI Custom NUR 316 Fall 2023 1MHE Module 4 - 1st 5 units Questions
Extract:
Question 1 of 5
A nurse on an inpatient mental health unit is caring for a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Depersonalization. In panic level anxiety, individuals may experience feelings of detachment from oneself, known as depersonalization. This is a common symptom where individuals feel like they are observing themselves from outside their bodies. This finding is expected in clients experiencing severe anxiety. Shakiness (
A) is more common in mild to moderate anxiety levels. Voice tremors (
C) may occur but are not specific to panic level anxiety. Poor concentration (
D) is a common symptom of anxiety but not specific to panic level anxiety.
Question 2 of 5
A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because stress is a common cause of depressed mood. Stress can lead to feelings of sadness and hopelessness. High blood pressure (
B), elevated heart rate (
C), and renal dysfunction (
D) are not typically direct causes of depressed mood. High blood pressure and elevated heart rate are more closely associated with physical health, while renal dysfunction is related to kidney function, not mental health.
Therefore, A is the best choice as it aligns with common triggers of depression.
Question 3 of 5
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Asking the client about the lethality of their plan is crucial in assessing the level of risk for self-harm. It helps determine the immediacy and seriousness of the situation. This information guides the nurse in developing a safety plan and appropriate interventions. Encouraging the client to focus on the positive aspects of life (
B) may overlook the severity of the situation. Reassuring the client that everything will work out (
C) may minimize their feelings and not address the underlying issue. Allowing the client time alone to self-reflect (
D) can be dangerous if the plan is lethal, as it increases the risk of harm.
Question 4 of 5
A nurse is caring for a client who ingested a selective serotonin reuptake inhibitor and St. John's Wort. Which of the following findings should the nurse identify as being consistent with serotonin syndrome?
Correct Answer: D
Rationale: The correct answer is D: Dilated pupils and loss of muscle coordination. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin levels in the body. Selective serotonin reuptake inhibitors and St. John's Wort can both increase serotonin levels. Dilated pupils and loss of muscle coordination are classic signs of serotonin syndrome due to the overstimulation of serotonin receptors in the brain. Blood pressure (choice
A) can be elevated, but it is not a specific finding for serotonin syndrome. Suicidal ideations (choice
B) are more related to mental health conditions rather than serotonin syndrome. Tinnitus and jerking movements (choice
C) are not typically associated with serotonin syndrome.
Question 5 of 5
A nurse is providing care to a client who has acute stress disorder. Which of the following client statements is consistent with this disorder?
Correct Answer: A
Rationale: The correct answer is A because acute stress disorder involves experiencing a traumatic event and experiencing symptoms such as nightmares within a month of the event.
Choice B is incorrect as it describes symptoms consistent with post-traumatic stress disorder rather than acute stress disorder.
Choice C involves childhood trauma, indicating potential PTSD instead of acute stress disorder.
Choices D, E, F, and G are unrelated to acute stress disorder.