ATI RN
ATI Mental Health
1. A client is experiencing a panic attack. Which action should the nurse take first?
- A. Remain with the client and offer reassurance.
- B. Administer an anti-anxiety medication as prescribed.
- C. Encourage the client to engage in physical activity.
- D. Encourage the client to breathe deeply and slowly.
Correct answer: A
Rationale: During a panic attack, the immediate priority for the nurse is to provide support and reassurance to the client. Remaining with the client helps establish a sense of safety and trust, which can help calm the client during an episode of panic. Administering medication, encouraging physical activity, and deep breathing techniques are beneficial interventions, but offering reassurance and support should be the initial step to address the immediate emotional distress and anxiety experienced by the client.
2. According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?
- A. A client rudely complaining about limited visiting hours
- B. A client exhibiting aggressive behavior toward another client
- C. A client stating that no one cares
- D. A client verbalizing feelings of failure
Correct answer: B
Rationale: The correct answer is B. According to Maslow's hierarchy of needs, safety needs are considered fundamental and must be addressed before higher-level needs. When a client exhibits aggressive behavior toward another client, it poses an immediate threat to safety and requires priority intervention by the nurse to ensure the well-being of all individuals involved. Clients who are rude in their complaints (Choice A), express feelings of failure (Choice D), or state that no one cares (Choice C) are addressing higher-level needs related to social interactions, esteem, and self-actualization, respectively, which can be addressed once safety needs are secured.
3. When explaining suicide precautions to a client, what would be the best explanation?
- A. You need to control yourself. If you cannot, we will do it for you.
- B. This can seem embarrassing, but we want you to be safe.
- C. You will stay on these precautions for one week.
- D. When you feel you are safer, then we will not need to observe you.
Correct answer: D
Rationale: Choice D provides a supportive and empowering explanation to the client on suicide precautions. It emphasizes the client's own sense of safety and control, indicating that the observation is temporary and can be removed when the client feels safer. This approach promotes autonomy and encourages the client to actively participate in their own well-being, fostering a therapeutic relationship based on trust and collaboration.
4. A patient with generalized anxiety disorder (GAD) is prescribed venlafaxine. The nurse should educate the patient about which potential side effect?
- A. Hypertension
- B. Hypotension
- C. Bradycardia
- D. Hyperglycemia
Correct answer: A
Rationale: The correct answer is A: Hypertension. Venlafaxine, an SNRI, can lead to hypertension as a side effect. This medication can cause an increase in blood pressure, particularly at higher doses. Educating the patient about this potential adverse effect is crucial to enhance awareness and monitoring for any signs or symptoms of elevated blood pressure. Choices B, C, and D are incorrect because venlafaxine is more likely to cause hypertension rather than hypotension, bradycardia, or hyperglycemia.
5. A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms shouldn't the nurse expect to observe during withdrawal?
- A. Tremors
- B. Hallucinations
- C. Diaphoresis
- D. Bradycardia
Correct answer: D
Rationale: During alcohol withdrawal, the nurse should expect to observe symptoms such as tremors, hallucinations, and diaphoresis. Seizures may also occur during severe withdrawal. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia (an increased heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the sympathetic nervous system.
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