a client states i am the only one who can hear voices which is the nurses best response
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

Correct answer: A

Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.

2. In a patient with bipolar disorder, which symptom would indicate a manic episode?

Correct answer: C

Rationale: The correct answer is C: Decreased need for sleep. A decreased need for sleep is a hallmark symptom of a manic episode in bipolar disorder. During manic episodes, individuals may experience significantly reduced sleep without feeling tired, which can lead to increased energy levels, impulsivity, and other manic symptoms. Excessive sleeping (choice A) is more indicative of depression rather than mania. Low self-esteem (choice B) and anhedonia (choice D) are also more commonly associated with depressive episodes rather than manic episodes in bipolar disorder.

3. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

Correct answer: D

Rationale: When caring for a client with schizophrenia experiencing delusions, the nurse should present reality and offer reassurance without reinforcing the client's delusions. This approach helps the client maintain a connection to reality while feeling supported. Agreeing with the delusions may perpetuate false beliefs, while directly challenging them can lead to increased distress for the client. Encouraging the client to discuss their delusions in detail may further exacerbate their symptoms or reinforce their false beliefs. Therefore, the most therapeutic intervention is to gently present reality and provide reassurance to the client.

4. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?

Correct answer: B

Rationale: A lithium level of 1.7 mEq/L is above the therapeutic range, indicating a potential risk of toxicity. The initial nursing intervention should be to instruct the patient to hold the next dose of medication and promptly contact the prescriber for further guidance and management. This action aims to prevent adverse effects and ensure the patient's safety by addressing the elevated lithium level appropriately.

5. A student finds that they come down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing?

Correct answer: C

Rationale: The student is most likely experiencing the stage of exhaustion. In this stage, the body's exposure to stress has been prolonged, and adaptive energy has been depleted. As a result, diseases of adaptation, such as the recurrent sinus infection in this case, are more likely to occur. The alarm reaction stage is the initial stage of the stress response, where the body perceives a threat and activates the fight-or-flight response. The stage of resistance is when the body tries to adapt and cope with the stressor. The fight-or-flight response is the immediate reaction to a perceived threat, involving physiological changes to prepare the body to either fight the stressor or flee from it.

Similar Questions

A healthcare provider is providing care for a patient with generalized anxiety disorder (GAD) who has been prescribed an SSRI. Which SSRI is commonly used for this condition?
A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms should the nurse expect to observe during withdrawal? Select one that doesn't apply.
A client prescribed lithium for bipolar disorder is receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?
A patient with schizophrenia is prescribed risperidone. The nurse should monitor the patient for which common side effect of this medication?
A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that doesn't apply.

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