ATI RN
ATI Mental Health Practice B
1. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?
- A. Encourage the client to express feelings about the suicide attempt.
- B. Place the client on one-to-one observation.
- C. Discuss the client's feelings about the suicide attempt.
- D. Encourage the client to participate in group therapy.
Correct answer: B
Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.
2. A healthcare professional is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptom shouldn't the healthcare professional expect?
- A. Fidgeting
- B. Laughing inappropriately
- C. Palpitations
- D. Nail biting
Correct answer: C
Rationale: Palpitations are not typically associated with moderate anxiety. Fidgeting, laughing inappropriately, and nail biting are common behavioral symptoms of heightened stress levels. Palpitations may be more indicative of physiological responses, such as increased heart rate, which can occur in severe anxiety or panic attacks. Other signs of severe anxiety include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.
3. A client with major depressive disorder is prescribed an antidepressant. Which of the following instructions should the nurse include in the teaching? Select the one that does not apply.
- A. It may take several weeks for the medication to take effect
- B. Avoid alcohol while taking this medication
- C. Discontinue the medication abruptly
- D. You may experience an increase in energy before your mood improves
Correct answer: C
Rationale: Teaching for a client prescribed an antidepressant should include several key instructions. Firstly, it's important to inform the client that it may take several weeks for the medication to take effect, so they should be patient. Secondly, they should be advised to avoid alcohol while taking the medication as it can interact negatively with antidepressants. Additionally, abrupt discontinuation of antidepressants can lead to withdrawal symptoms and should be avoided. Lastly, clients may experience an increase in energy before their mood improves, which is a common effect of some antidepressants. Regular blood tests are not typically required for most antidepressants, but adherence to the prescribed regimen and reporting any concerning side effects to the healthcare provider are crucial.
4. A client with generalized anxiety disorder (GAD) is being discharged. Which of the following instructions should the nurse include in the discharge teaching? Select one that does not apply.
- A. Practice relaxation techniques daily
- B. Avoid caffeine and alcohol
- C. Engage in regular physical activity
- D. Use benzodiazepines as the first line of treatment
Correct answer: D
Rationale: When discharging a client with GAD, it is important to provide instructions that promote holistic well-being and support without exacerbating the condition. Practicing relaxation techniques daily, avoiding caffeine and alcohol, and engaging in regular physical activity can help manage anxiety symptoms effectively. These strategies focus on self-care and healthy lifestyle choices. Seeking support from friends and family also plays a crucial role in maintaining mental health. However, using benzodiazepines as the first line of treatment is not recommended due to their potential for dependence and other associated risks. Non-pharmacological interventions and therapy are usually preferred as initial approaches in managing GAD. Therefore, the option 'D: Use benzodiazepines as the first line of treatment' is incorrect and should not be included in the discharge teaching for a client with GAD.
5. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?
- A. Allow the client to continue the ritualistic behavior initially
- B. Immediately stop the client from performing the ritual
- C. Encourage the client to perform the ritual more quickly
- D. Provide a distraction to interrupt the ritual
Correct answer: A
Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.
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