ATI RN Mental Custom Health Next Gen -Nurselytic

Correct Answer: C

Rationale: The correct answer is C because it demonstrates active listening and encourages the patient to express their experiences. By asking "You say you hear voices, what are they telling you?" the nurse shows empathy, validation, and a non-judgmental attitude towards the patient's altered thought processes. This statement helps the patient feel heard and understood, fostering a therapeutic nurse-patient relationship.


Choice A is incorrect because it dismisses the patient's experience and does not acknowledge their reality.
Choice B is incorrect as it commands the patient to stop listening to the voices without addressing the underlying issues.
Choice D is incorrect because it suggests the patient has control over the voices, which may not be the case.

Correct Answer: D

Rationale: The correct answer is D: They are not actually ill. Anosognosia is a symptom of schizophrenia where patients lack awareness of their illness. This leads them to deny their condition and refuse treatment.
Choice A is incorrect as it assumes patients are aware of the medication's effectiveness.
Choice B is incorrect as it introduces a paranoid belief not related to anosognosia.
Choice C is incorrect as it focuses on physical side effects, not denial of illness.

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 symptoms of acute dystonia, a side effect of haloperidol. Benztropine is a commonly used anticholinergic medication that can quickly reverse these symptoms. It is important to address this promptly to prevent further complications. Holding the medication and contacting the prescriber (choice
A) can be done after addressing the acute symptoms. Wiping the patient with cold water or alcohol (choice
B) may provide temporary relief but does not address the underlying cause. Reassuring the patient about tardive dyskinesia (choice
D) is incorrect as the current symptoms are not related to tardive dyskinesia.

Correct Answer: B

Rationale: The correct answer is B: Remain calm and use a matter-of-fact approach. This approach is essential to provide a sense of safety and security for the client experiencing extreme anxiety. By remaining calm, the nurse can model a calming presence and help the client feel more at ease. Using a matter-of-fact approach can help normalize the situation and reassure the client that her feelings are valid but manageable.

A: Assisting the client in developing coping skills may be beneficial in the long term, but in this acute situation, the immediate focus should be on providing immediate support.
C: Asking the client why she is anxious may not be helpful as it can potentially increase her anxiety or lead to a delusional explanation.
D: Administering a sedative should not be the first intervention as it does not address the underlying cause of the anxiety and may mask important information that could help in providing appropriate care.

In summary, the most important intervention is remaining calm and using a matter-of-fact

Correct Answer: A

Rationale: The correct answer is A: Acute confusion. This is the priority problem because the client is disoriented, disorganized, and confused, indicating an altered mental status requiring immediate attention. Addressing acute confusion is crucial to ensure the client's safety and well-being.

Incorrect

Choices:
B: Ineffective community coping is not the priority as the client's immediate cognitive impairment takes precedence.
C: Disturbed sensory perception does not align with the client's presentation of confusion and disorientation.
D: Self-care deficit may be a concern but is secondary to the acute confusion that needs urgent intervention.