ATI RN
ATI N200 Mental Health Exam 3 Questions
Extract:
Question 1 of 5
The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?
Correct Answer: D
Rationale: The correct answer is D: Dizziness. Lorazepam is a benzodiazepine commonly associated with central nervous system depressant effects, including dizziness. This side effect occurs due to the drug's impact on the neurotransmitter GABA in the brain, leading to sedative and calming effects. Hypertension (
A) is not a common side effect of lorazepam; tinnitus (
B) is more associated with ototoxic medications; metallic taste (
C) is not a typical side effect of lorazepam. In summary, dizziness is the expected side effect due to lorazepam's mechanism of action, while the other choices are less likely to occur.
Question 2 of 5
A client on an acute psychiatric inpatient unit approaches the nurse's station every 10-15 minutes with various requests. The nurse intervenes by stating,You may approach the nurse's station only once an hour. Which nursing intervention has been employed?
Correct Answer: A
Rationale: The correct answer is A: Confirming boundaries by setting limits on behavior. By instructing the client to approach the nurse's station only once an hour, the nurse is establishing clear boundaries and limits on the client's behavior. This intervention helps maintain structure and consistency within the unit, promotes appropriate interaction patterns, and prevents the client from becoming overly dependent on constant attention.
Other choices are incorrect because:
B: Providing reality orientation is not the correct response in this situation as the client's behavior is not related to confusion or disorientation.
C: Providing client education in a direct manner is not relevant to the scenario where the issue is about setting boundaries for behavior.
D: Ensuring physical need fulfillment is not the appropriate intervention in this case as the client's requests are not related to physical needs.
Question 3 of 5
The client hears the word "match." The client replies,"A match is a catch. A catch is a batch. The batch started to hatch. Which communication pattern does the nurse identify?
Correct Answer: C
Rationale: The correct answer is C: Clang association. Clang association is a type of disorganized thinking where words are connected by sound rather than meaning. In this scenario, the client's response is characterized by the rhyming of words based on their sound similarity rather than their actual connection in meaning. This demonstrates a lack of logical thought process and coherence in their communication. Word salad (
A) refers to a jumble of unrelated words, Loose association (
B) involves shifting from one topic to another without logical connection, and Ideas of reference (
D) is the belief that unrelated events or comments are directed at oneself. These choices do not accurately describe the communication pattern exhibited in the client's response.
Question 4 of 5
A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?
Correct Answer: A
Rationale: The correct answer is A. In somatoform disorders, individuals experience physical symptoms that cannot be fully explained by a general medical condition.
Therefore, it is crucial for clients with somatoform disorders to have any new medical complaint evaluated to rule out any underlying medical conditions that may be causing their symptoms. This is important for proper diagnosis and treatment planning.
Choice B is incorrect because somatoform disorders are complex and typically require a combination of therapies, including therapy and medication management. There is no single cure with medication alone.
Choice C is incorrect because individuals with somatoform disorders do not have a specific underlying medical diagnosis for their symptoms.
Choice D is incorrect because individuals with somatoform disorders are not intentionally pretending to have physical symptoms; rather, they genuinely experience these symptoms.
Overall, choice A is the most appropriate and accurate response given the nature of somatoform disorders and the importance of thorough evaluation of new medical complaints in this population.
Question 5 of 5
Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?
Correct Answer: B
Rationale: The most appropriate nursing strategy when caring for a delusional individual is to focus on what is happening in the here and now (choice
B). This approach helps to ground the individual in reality and reduce the influence of their delusions. By focusing on the present moment, the nurse can help the individual stay connected to their immediate surroundings and potentially decrease the intensity of their delusions. Asking open-ended questions (choice
A) may inadvertently reinforce the delusions by allowing the individual to elaborate on their false beliefs. Assuming knowledge of what is meant when the client talks about 'they' (choice
C) can contribute to confusion and misinterpretation. Limiting contact to one or two short interactions daily (choice
D) may not provide enough support and intervention for the individual's needs.