Review ATI N200 Mental Health Exam 1

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ATI N200 Mental Health Exam 1

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Total Questions : 64

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Question 1:

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

A. There are any signs of infection. B. There is a decrease in hallucinations. C. Appetite continues to decrease after one week. D. Insomnia occurs for more than two nights.

Answer and Explanation

Choice A:

: Clozapine is known to cause agranulocytosis, a potentially life-threatening condition where the white blood cell count drops significantly, leading to a higher risk of infection. Patients on clozapine must have regular blood tests to monitor their white blood cell count. Any signs of infection, such as fever, sore throat, or flu-like symptoms, should be reported to a physician immediately as they could indicate agranulocytosis.

Choice B:

o call the physician immediately. Instead, this should be discussed during regular follow-up appointments to assess the overall effectiveness of the treatment.

Choice C:

: While a decrease in appetite can be a side effect of clozapine, it is not typically an emergency unless it leads to significant weight loss or malnutrition. This should be monitored and discussed with the physician during regular visits. If the decrease in appetite is severe or persistent, it may warrant a call to the physician, but it is not as urgent as signs of infection.

Choice D:

: Insomnia can occur with clozapine use, but it is usually managed with adjustments to the medication regimen or additional treatments for sleep. While it is important to address insomnia, it does not require immediate medical attention unless it severely impacts the patient’s well-being.

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Question 2:

A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?

A. Your mother seems like an understanding person. I’ll help you approach her. B. It’s quite common for clients to feel that way after a lengthy hospitalization. C. Why don’t you talk to your mother? You may find out she doesn’t feel that way. D. You feel that your mother does not want you to come back home.

Answer and Explanation

Choice A:

: While this response attempts to offer support, it makes an assumption about the mother’s understanding without addressing the client’s feelings directly. Therapeutic communication should focus on validating the client’s emotions and encouraging them to express their thoughts and feelings. This response might not fully acknowledge the client’s distress.

Choice B:

: This response normalizes the client’s feelings, which can be helpful, but it does not directly address the client’s specific concern. While it is important to reassure the client that their feelings are common, the response should also validate their individual experience and encourage further discussion.

Choice C:

: Encouraging the client to talk to their mother is a proactive suggestion, but it may not be the most therapeutic initial response. The client might not be ready to take that step, and the nurse should first focus on understanding and validating the client’s feelings before suggesting actions. This response could be more appropriate as a follow-up after the client’s feelings have been explored.

Choice D:

: This response is the most therapeutic because it uses reflective listening to validate the client’s feelings. By restating what the client has expressed, the nurse shows empathy and encourages the client to explore their emotions further. This technique helps the client feel heard and understood, which is crucial in therapeutic communication.

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Question 3:

A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

A. I may consider dating you once you have fully recovered. B. It’s against hospital policy for me to date clients. C. This is a professional relationship, and we need to be clear on that. D. I’m sorry, but I’m married and not interested in dating.

Answer and Explanation

Choice A:

: This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.

Choice B:

: While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.

Choice C:

: This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.

Choice D:

for declining the request.

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Question 4:

Upon assessment of the lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

A. Wheezes B. Rhonchi C. Fine crackles D. Vesicular sounds

Answer and Explanation

Choice A:

: Wheezes are continuous, high-pitched, musical sounds that occur when air flows through narrowed or obstructed airways1. They can be heard during both inspiration and expiration and are commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis. Wheezes are a key indicator of airway obstruction and require prompt medical attention to address the underlying cause.

Choice B:

: Rhonchi are low-pitched, continuous sounds that resemble snoring or gurgling. They are typically caused by secretions or obstructions in the larger airways. Unlike wheezes, rhonchi are not high-pitched and do not have a musical quality. They are often heard in conditions like chronic bronchitis and can sometimes be cleared with coughing.

Choice C:

: Fine crackles are discontinuous, high-pitched popping sounds heard during inspiration. They are caused by the sudden opening of small airways and alveoli that are collapsed or filled with fluid. Fine crackles are often associated with conditions such as pneumonia, heart failure, and pulmonary fibrosis. They are not continuous sounds and do not have the musical quality of wheezes.

Choice D:

: Vesicular sounds are normal breath sounds heard over most of the lung fields. They are soft, low-pitched, and rustling in quality during inspiration and are fainter during expiration. Vesicular sounds indicate normal, unobstructed airflow through the small airways and alveoli. They are not continuous or high-pitched and do not have a musical quality.

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Question 5:

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

A. Encourage social interaction. B. Discuss the bizarre behavior. C. Give the client information about her illness. D. Provide a safe environment.

Answer and Explanation

Choice A:

: Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B:

: Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C:

: Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D:

: Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.

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Question 6:

A patient with fluid volume deficit must receive a 250 mL IV bolus of NS over 25 minutes via a peripherally inserted central line (PICC) on an IV pump. At what rate will the nurse program the pump? Round to the nearest whole number. Do not use trailing zeros.

Answer and Explanation

Correct Answer: "600" mL/hour

Explanation

Step 1: Identify the total volume to be infused.

Total volume = 250 mL

Step 2: Identify the total time for infusion.

Total time = 25 minutes

Step 3: Calculate the rate in mL per minute.

Rate = Total volume ÷ Total time
Rate = 250 mL ÷ 25 minutes
Rate = 10 mL per minute

Step 4: Convert the rate to mL per hour.

Since there are 60 minutes in an hour, multiply the rate by 60.
Rate per hour = 10 mL per minute × 60
Rate per hour = 600 mL per hour

The nurse should program the pump to infuse at a rate of 600 mL per hour.

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Question 7:

A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?

A. “You should share this thought with your psychiatrist.” B. “I can make that promise to you based on nurse-client privilege.” C. “Those kinds of thoughts will make your hospitalization longer.” D. “I cannot promise that. Confidentiality does not include plans to hurt others.”

Answer and Explanation

Choice A:

: “You should share this thought with your psychiatrist.” This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.

Choice B:

: “I can make that promise to you based on nurse-client privilege.” This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.

Choice C:

: “Those kinds of thoughts will make your hospitalization longer.” This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.

Choice D:

: “I cannot promise that. Confidentiality does not include plans to hurt others.” This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.

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Question 8:

A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

A. Ask the client direct questions about the hallucinations. B. Act as if the hallucinations are real. C. Instruct the client to argue with the voices. D. Explain to the client that the hallucinations will subside soon.

Answer and Explanation

Choice A:

: Ask the client direct questions about the hallucinations. This response is the most appropriate because it allows the nurse to assess the content and nature of the hallucinations directly. By understanding what the client is experiencing, the nurse can better evaluate the risk of harm to the client or others and develop an appropriate care plan. Direct questioning helps in identifying whether the hallucinations are commanding the client to perform harmful actions, which is crucial for ensuring safety. This approach aligns with therapeutic communication techniques that emphasize understanding the client’s experience and providing appropriate interventions.

Choice B:

: Act as if the hallucinations are real. This response is not appropriate because it can reinforce the client’s delusions and hallucinations, making it harder for them to distinguish between reality and their hallucinations. It is important for the nurse to maintain a reality-based approach while being empathetic and supportive. Acknowledging the client’s feelings without validating the hallucinations helps in maintaining a therapeutic environment.

Choice C:

: Instruct the client to argue with the voices. Instructing the client to argue with the voices is not recommended as it can increase the client’s distress and confusion. Instead, the nurse should help the client develop coping strategies to manage the hallucinations, such as distraction techniques or reality testing. Encouraging the client to engage in a confrontation with their hallucinations can exacerbate their symptoms and is not a therapeutic approach.

Choice D:

: Explain to the client that the hallucinations will subside soon. This response is not appropriate because it provides false reassurance. Hallucinations may not subside quickly, and the client needs realistic support and coping strategies to manage their symptoms. Providing false hope can undermine the client’s trust in the nurse and the treatment process. Instead, the nurse should focus on helping the client manage their symptoms effectively.

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Question 9:

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an:

A. manifestation of dyslexia. B. example of loose associations. C. neologism. D. flight of ideas.

Answer and Explanation

Choice A:

: Manifestation of dyslexia. Dyslexia is a learning disorder characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. It is not typically associated with the creation of new words or phrases, which is what the term ‘mazurka’ represents in this context. Therefore, the client’s use of ‘mazurka’ is not a manifestation of dyslexia.

Choice B:

: Example of loose associations. Loose associations refer to a thought disorder where ideas are presented with little or no logical connection between them. While this is a common symptom in schizophrenia, it does not specifically involve the creation of new words. The term ‘mazurka’ in this context does not illustrate a lack of logical connection between ideas but rather the invention of a new term.

Choice C:

: Neologism. Neologism refers to the creation of new words or phrases that are often only understood by the person who created them. This is a common symptom in schizophrenia, where individuals may invent words that have meaning only to them. The client’s use of ‘mazurka’ fits this definition, as it is a newly created word that likely holds specific meaning for the client.

Choice D:

: Flight of ideas. Flight of ideas is a symptom characterized by rapid and continuous speech with abrupt changes from topic to topic, usually based on understandable associations, distracting stimuli, or plays on words. This symptom is more commonly associated with manic episodes rather than schizophrenia. The use of ‘mazurka’ does not indicate rapid topic changes but rather the creation of a new word.

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Question 10:

A patient is prescribed morphine sulfate 5 mg IV every 4 hours as needed for a pain level greater than 7 on a scale of 0-10. Morphine is available in 8 mg/mL vials. How many mL will the nurse give for the correct dose?

Round to the nearest hundredth. Use a preceding zero if necessary. Do not use trailing zeros.

Answer and Explanation

Correct Answer: "0.63" mL

Explanation

To calculate the correct dose:

Identify the prescribed dose: 5 mg
Identify the concentration of the available morphine: 8 mg/mL
Calculate the volume to be administered:
- Volume (mL) = Prescribed dose (mg) ÷ Concentration (mg/mL)
- Volume (mL) = 5 mg ÷ 8 mg/mL
- Volume (mL) = 0.625 mL

The nurse will give 0.63 mL (rounded to the nearest hundredth) for the correct dose.

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ATI N200 Mental Health Exam 1

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