Review ATI RN Mental health 2019 NGN II

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ATI RN Mental health 2019 NGN II

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Total Questions : 70

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Question 1:

A nurse is caring for a client who has schizophrenia and is taking clozapine.
Which of the following findings is the priority for the nurse to report to the provider?

A. Random blood glucose 130 mg/dL. B. Nausea. C. Heart rate 104/min. D. Sore throat.

Answer and Explanation

Choice A:

Random blood glucose 130 mg/dL is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 70 to 110 mg/dL, but it is not indicative of a serious condition such as diabetes mellitus or hyperglycemia. Clozapine can cause hyperglycemia in some patients, but this is usually a chronic effect that develops over months or years of treatment. Therefore, a single random blood glucose measurement of 130 mg/dL is not a cause for immediate concern or intervention. The nurse should monitor the client’s blood glucose levels regularly and educate the client on the signs and symptoms of hyperglycemia, such as increased thirst, urination, hunger, and fatigue. The nurse should also encourage the client to maintain a healthy diet and exercise regimen to prevent or manage hyperglycemia.

Choice B:

Nausea is not a priority finding for the nurse to report to the provider. Nausea is a common side effect of clozapine that usually occurs during the initial phase of treatment or after a dose increase. It is usually mild and transient and can be managed by taking the medication with food or water, using antiemetics, or reducing the dose if necessary. Nausea does not indicate a serious or life-threatening adverse reaction to clozapine, unless it is accompanied by other symptoms such as vomiting, abdominal pain, jaundice, or fever. The nurse should assess the client’s nausea and provide supportive care and education on how to cope with it.

Choice C:

Heart rate 104/min is not a priority finding for the nurse to report to the provider. This level is slightly above the normal range of 60 to 100 beats per minute, but it is not indicative of a serious condition such as tachycardia or cardiac arrhythmia. Clozapine can cause orthostatic hypotension, bradycardia, syncope, and cardiac arrest in some patients, but these are rare and serious adverse effects that require immediate medical attention. Therefore, a single heart rate measurement of 104/min is not a cause for immediate concern or intervention. The nurse should monitor the client’s vital signs regularly and educate the client on the signs and symptoms of orthostatic hypotension, such as dizziness, lightheadedness, or fainting when changing positions. The nurse should also advise the client to rise slowly from a lying or sitting position, avoid alcohol and other substances that can lower blood pressure, and drink plenty of fluids to prevent dehydration.

Choice D:

Sore throat is a priority finding for the nurse to report to the provider. Sore throat is a sign of infection, inflammation, or irritation of the throat, which can be caused by various factors such as viruses, bacteria, allergens, or irritants. However, in a client who is taking clozapine, sore throat can also indicate a serious and potentially fatal adverse effect of the medication: severe neutropenia. Neutropenia is a condition in which the number of neutrophils, a type of white blood cell that fights infection, is abnormally low. This increases the risk of developing serious and life-threatening infections, especially in the mouth, throat, and respiratory tract. Clozapine can cause neutropenia in some patients, especially during the first 18 weeks of treatment, and it is the most common reason for discontinuing the medication. Therefore, any client who is taking clozapine and develops a sore throat should be evaluated by the provider as soon as possible to rule out neutropenia and initiate appropriate treatment if needed. The nurse should also educate the client on the importance of regular blood tests to monitor the absolute neutrophil count (ANC) and the signs and symptoms of infection, such as fever, chills, weakness, or sore throat. The nurse should also instruct the client to avoid contact with people who are sick, practice good hygiene, and report any signs of infection immediately.

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Question 2:

A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.”. The client has tachycardia and hypertension.
The nurse should suspect acute toxicity of which of the following substances?

A. Alcohol. B. Heroin. C. Opium. D. Cocaine.

Answer and Explanation

Choice A:

Alcohol toxicity typically presents with symptoms such as confusion, slurred speech, and ataxia, rather than paranoia ("People are out to get me"). While alcohol can cause increased heart rate and blood pressure, it is not the most likely substance to cause these symptoms in the context of paranoia.

Choice B:

Heroin toxicity is characterized by central nervous system depression, pinpoint pupils, and respiratory depression, which do not align with the client's symptoms of paranoia, tachycardia, and hypertension.

Choice C:

Opium toxicity shares some similarities with heroin toxicity, including central nervous system depression and pinpoint pupils. It is not typically associated with paranoia or the vital sign changes described in the scenario.

Choice D:

Cocaine toxicity is the most likely cause of the client's symptoms. Cocaine can lead to paranoia, tachycardia, and hypertension. The combination of these symptoms suggests acute cocaine toxicity, making it the priority concern for the nurse. Prompt intervention is necessary to address the potential life-threatening effects of cocaine toxicity.

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Question 3:

A nurse is receiving change-of-shift report for four clients.
Which of the following clients should the nurse see first?

A. A client who has bipolar disorder and is speaking loudly. B. A client who has schizophrenia and is experiencing olfactory hallucinations. C. A client who is taking clozapine and reports a sore throat. D. A client who is taking lithium and reports weight gain.

Answer and Explanation

Choice A:

A client with bipolar disorder who is speaking loudly is displaying a manic symptom, which may require attention but is not the highest priority among the options. It does not pose an immediate risk to the client's physical health.

Choice B:

A client with schizophrenia experiencing olfactory hallucinations may be distressed, but this is not an immediate physical health concern. It may require attention but is not the highest priority.

Choice C:

A client taking clozapine who reports a sore throat should be seen first. Clozapine is associated with a risk of agranulocytosis, a severe condition that can lead to a dangerously low white blood cell count. A sore throat can be an early sign of infection, and in the context of clozapine use, it is crucial to assess and monitor for agranulocytosis promptly. This condition is life-threatening and requires immediate attention to prevent complications. .

Choice D:

Weight gain is a potential side effect of lithium, and while it should be monitored and addressed, it is not a critical finding that requires immediate attention.

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Question 4:

A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm.
Which of the following actions should the nurse take?

A. Withhold the next dose of the medication. B. Ask the client about a recent change in laundry detergent. C. Apply hydrocortisone cream on the client's rash. D. Explain that the medication causes a temporary rash.

Answer and Explanation

Choice A:

Withholding the next dose of the medication is not the initial action the nurse should take in response to the client's report of a rash. Lamotrigine can cause a severe skin reaction known as Stevens-Johnson syndrome, which is a medical emergency. However, discontinuing the medication abruptly without further assessment is not appropriate. The nurse should first gather more information to determine the cause of the rash.

Choice B:

Asking the client about a recent change in laundry detergent is a reasonable and responsible action. Skin rashes can be caused by various factors, including contact dermatitis from laundry detergents, soaps, or other irritants. By inquiring about potential changes in the client's environment or routines, the nurse can gather important information to help identify the cause of the rash.

Choice C:

Applying hydrocortisone cream on the client's rash without a proper assessment is not advisable. While hydrocortisone cream can help relieve itching and inflammation, it may not address the underlying cause of the rash, especially if it is due to a severe drug reaction like Stevens-Johnson syndrome.

Choice D:

Explaining that the medication causes a temporary rash is inaccurate and not recommended. While lamotrigine can cause a mild rash in some individuals, it can also lead to more serious skin reactions, as mentioned earlier. It's important to take any rash associated with lamotrigine seriously and investigate its cause before making assumptions about its temporary nature.

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Question 5:

A nurse is caring for a client who has a personality disorder and is using transference to cope.
Which of the following behaviors should the nurse expect?

A. Expressing frustration regarding unit rules. B. Reacting to the nurse as though she were his mother. C. Refusing to participate in group activities. D. Talking negatively about other staff members.

Answer and Explanation

Choice A:

Expressing frustration regarding unit rules is a possible behavior, but it doesn't directly relate to transference. It may reflect the client's general frustration or non-compliance with the rules, but it doesn't necessarily involve the transfer of feelings from a past relationship.

Choice C:

Refusing to participate in group activities can be a behavior related to a personality disorder, but it's not specifically indicative of transference. It may be more related to the client's avoidance or social difficulties.

Choice D:

Talking negatively about other staff members is another behavior that may occur in individuals with personality disorders, but it doesn't directly demonstrate transference. It could be a manifestation of their interpersonal difficulties or conflicts with staff.

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Question 6:

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

A. Auditory hallucinations. B. Flight of ideas. C. Decreased motivation. D. Impaired memory.

Answer and Explanation

Choice A:

Auditory hallucinations are considered a positive symptom of schizophrenia. Positive symptoms are characterized by the presence of abnormal experiences or behaviors that are not typically present in individuals without schizophrenia. Auditory hallucinations involve hearing voices or sounds that are not real.

Choice B:

Flight of ideas is a positive symptom of schizophrenia. It is characterized by a rapid and disorganized flow of thoughts, often leading to incoherent speech. This symptom is part of the formal thought disorder commonly seen in individuals with schizophrenia.

Choice C:

Decreased motivation is not a positive symptom; it is considered a negative symptom of schizophrenia. Negative symptoms are characterized by a reduction or loss of normal functions or behaviors that are typically present in healthy individuals. Decreased motivation reflects a lack of interest, energy, or drive to engage in activities.

Choice D:

Impaired memory is not a positive symptom but is more associated with cognitive deficits, which can be a part of schizophrenia, but it falls under cognitive symptoms rather than positive symptoms.

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Question 7:

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder.
The client states, "I feel unmotivated and don't feel like leaving my home.”. Which of the following recommendations should the nurse make to address the client's social isolation?

A. Enroll in an online self-help course. B. Practice guided imagery each morning. C. Write in a journal daily. D. Join a low-impact exercise class.

Answer and Explanation

Choice A:

Enroll in an online self-help course:While this can be beneficial for learning coping skills,it doesn't directly address the social isolation aspect.

Choice B:

Practice guided imagery each morning:This could be helpful for emotional regulation but doesn't necessarily promote socialization.

Choice C:

Write in a journal daily:Though journaling can be therapeutic,it's a solitary activity and may not address social withdrawal.

Choice D:

Join a low-impact exercise class:Participating in a group activity like a low-impact exercise class provides several benefits:
- Physical activity:Improves mood and energy levels,reducing depression symptoms.
- Social interaction:Creates opportunities to connect with others with similar interests,combating isolation.
- Structure and routine:Provides a sense of purpose and accomplishment,which can be difficult with depression.
- Reduced stress:Exercise releases endorphins,which have mood-boosting effects.

Furthermore, a low-impact class caters to the client's potential lack of motivation and energy.

Therefore, encouraging participation in a low-impact exercise class is the most suitable recommendation for this client's social isolation in the context of depression.

Remember, it's crucial to consider the client's individual preferences and tailor recommendations accordingly.

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Question 8:

A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse.
Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

A. "The client asked me to go on a date with him, but I refused.”. B. "The client needs to accept responsibility for his substance use.”. C. "The client is just like my brother who finally overcame his habit.”. D. "The client generally shares his feelings during group therapy sessions.”.

Answer and Explanation

Choice A:

"The client asked me to go on a date with him, but I refused.”. This statement does not demonstrate countertransference. It is a clear example of professional boundaries being maintained, as the staff nurse refused the client's request for a date, which is appropriate in the context of the nurse-client relationship.

Choice B:

"The client needs to accept responsibility for his substance use.”. This statement does not indicate countertransference. It reflects a common and appropriate therapeutic goal, which is to help clients take responsibility for their actions and substance use disorder.

Choice C:

"The client is just like my brother who finally overcame his habit.”. This statement represents countertransference. Countertransference occurs when a healthcare professional's emotions, attitudes, or past experiences influence their perceptions and interactions with a client. In this case, the staff nurse is making a connection between the client and their own brother, suggesting a personal bias based on past experiences. This can hinder the staff nurse's ability to provide objective care.

Choice D:

"The client generally shares his feelings during group therapy sessions.”. This statement does not demonstrate countertransference. It is a straightforward observation of the client's behavior during group therapy sessions and does not involve any emotional or personal bias on the part of the staff nurse.

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Question 9:

A nurse is developing a behavioral contract with a client who has antisocial personality disorder.
Which of the following client goals should the nurse include in the contract?

A. Use projection during group therapy. B. Decrease the number of verbal outbursts. C. Increase self-esteem. D. Use bargaining skills for behavioral consequences.

Answer and Explanation

Choice A:

Use projection during group therapy. Projection involves attributing one's own thoughts, feelings, or characteristics to another person. It is not an appropriate goal for a client with antisocial personality disorder in a therapeutic setting. Instead, the focus should be on helping the client take responsibility for their actions and develop pro-social behaviors.

Choice B:

Decrease the number of verbal outbursts. This is a suitable goal for a client with antisocial personality disorder. Clients with this disorder may exhibit impulsive and aggressive behaviors, including verbal outbursts. Decreasing such outbursts is a positive therapeutic goal that can contribute to improved interpersonal relationships and overall functioning.

Choice C:

Increase self-esteem. While improving self-esteem is important in many therapeutic settings, it may not be the primary goal for a client with antisocial personality disorder. The primary focus is often on addressing antisocial behaviors, impulsivity, and aggression, as these are the hallmark traits of this disorder.

Choice D:

Use bargaining skills for behavioral consequences. Using bargaining skills may not be the most appropriate goal for a client with antisocial personality disorder. This disorder is characterized by a persistent pattern of violating the rights of others and a disregard for social norms. Instead of bargaining, the emphasis should be on developing empathy, impulse control, and more pro-social ways of interacting with others. .

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Question 10:

A nurse is caring for a client who has depression following a recent job loss.
Which of the following questions should the nurse ask to assess the client's personal coping skills?

A. "How have you dealt with similar situations in the past?". B. "Can you describe how you are currently feeling?". C. "Do you see your current situation affecting your future?". D. "How does this situation affect your life?".

Answer and Explanation

Choice A:

The nurse should ask the client, "How have you dealt with similar situations in the past?" This question is essential to assess the client's personal coping skills. By inquiring about the client's previous experiences in handling similar situations, the nurse can gain insight into the client's coping mechanisms and identify potential strengths and weaknesses. Understanding how the client has coped in the past can help tailor interventions and support to their specific needs.

Choice B:

While asking, "Can you describe how you are currently feeling?" is a valuable question, it primarily focuses on the client's current emotional state and may not provide a comprehensive assessment of their coping skills. It is crucial to understand the client's emotions, but it does not directly address their coping strategies.

Choice C:

"Do you see your current situation affecting your future?" is a forward-looking question that explores the client's perception of how their current situation might impact their future. While this question is relevant, it does not directly assess the client's coping skills and strategies. It focuses more on the client's expectations and outlook.

Choice D:

"How does this situation affect your life?" is a broad question that can provide insights into the client's life and the impact of their current situation. However, it does not specifically address the client's coping skills and strategies. It may provide information about the consequences of their situation but not their ability to cope.

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ATI RN Mental health 2019 NGN II

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