ATI RN
ATI RN Mental Custom Health Next Gen Questions
Extract:
Question 1 of 5
Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Administer a medication such as benztropine IM to correct this dystonic reaction. The patient is exhibiting signs of acute dystonia, a side effect of haloperidol characterized by sustained muscle contractions. Benztropine is an anticholinergic medication that can help alleviate these symptoms quickly. Holding the medication (option
A) is not the priority as the immediate focus should be on managing the acute symptoms. Wiping with cold water or alcohol (option
B) may provide temporary relief but does not address the underlying issue. Reassuring the patient about tardive dyskinesia (option
D) is not relevant at this point as the priority is to address the acute dystonic reaction.
Question 2 of 5
Which statement made by the nurse demonstrates the best understanding of nonverbal communication?
Correct Answer: B
Rationale: The correct answer is B because it demonstrates an understanding of the importance of congruence between verbal and nonverbal communication in validating responses. Checking for alignment between verbal and nonverbal cues helps ensure accurate interpretation of the patient's message. Option A is incorrect as it states a general observation without emphasizing the significance of congruence. Option C is incorrect because assuming emotions based solely on body language can lead to misinterpretations. Option D is incorrect as it undermines the complexity and importance of nonverbal communication.
Question 3 of 5
A client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale:
Setting a specific limit on the number of times the client can check the door is the most appropriate intervention because it addresses the client's compulsive behavior while also providing structure and boundaries. By setting limits, the client can gradually learn to trust the initial checking and reduce the need for reassurance, promoting independence and self-regulation. This intervention also aligns with cognitive-behavioral therapy principles for treating OCD by encouraging exposure and response prevention.
Summary of other choices:
B: Helping the client find an alternative activity does not directly address the compulsive checking behavior associated with OCD.
C: Providing consistent reassurance reinforces the client's checking behavior and does not promote long-term independence.
D: Ignoring the checking behavior may lead to increased anxiety and does not address the underlying issue of OCD.
Question 4 of 5
A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
Correct Answer: B
Rationale: The correct answer is B: "I can hear that your sister comments are overwhelming you." This response demonstrates empathy and active listening, acknowledging the client's feelings without dismissing them. It validates the client's experience and fosters a therapeutic relationship.
Choice A is incorrect as it dismisses the client's feelings and does not address the underlying issue.
Choice C can be perceived as confrontational and may make the client defensive.
Choice D is a good therapeutic technique but does not directly address the client's emotional distress caused by her sister's comments. Overall, choice B is the best response as it shows empathy and understanding towards the client's situation.
Question 5 of 5
The nurse administers each of the following drugs to various patients. The patient who should be most carefully assessed for fluid and electrolyte imbalance is the one receiving:
Correct Answer: A
Rationale: The correct answer is A: Lithium (Eskalith). Lithium is known to cause significant fluid and electrolyte imbalances, particularly affecting sodium levels. Patients on lithium therapy require close monitoring of their electrolyte levels to prevent adverse effects such as dehydration or hyponatremia. Clozapine (
B), Diazepam (
C), and Amitriptyline (
D) do not typically have as profound effects on fluid and electrolyte balance as lithium.
Therefore, they do not require the same level of monitoring for these imbalances.