ATI RN
ATI Mental Health
1. 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.
2. A client has been diagnosed with paranoid personality disorder. Which of the following behaviors should the nurse expect?
- A. Distrust of others
- B. Reluctance to confide in others
- C. Suspiciousness of others
- D. Jealousy of others
Correct answer: A
Rationale: Individuals with paranoid personality disorder commonly display a pervasive distrust of others. They often interpret benign actions of others as hostile or malicious, leading to suspicion and a belief that others have malevolent intentions. While choices B, C, and D may be present in individuals with different personality disorders or issues, distrust of others is a hallmark feature of paranoid personality disorder, making it the correct behavior to expect in these clients.
3. A client with obsessive-compulsive disorder (OCD) spends several hours each day washing her hands. Which intervention should the nurse implement?
- A. Encourage the client to wash her hands less frequently.
- B. Set a time limit for hand washing.
- C. Teach the client relaxation techniques.
- D. Discourage the client from washing her hands.
Correct answer: B
Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.
4. Which of the following interventions should a nurse include in the care plan for a client with major depressive disorder? Select one that is not appropriate.
- A. Encourage participation in activities
- B. Promote adequate nutrition and hydration
- C. Discourage verbalization of feelings
- D. Monitor for suicidal ideation
Correct answer: C
Rationale: Interventions for a client with major depressive disorder should focus on encouraging participation in activities, promoting adequate nutrition and hydration, monitoring for suicidal ideation, and providing a structured daily schedule. Discouraging verbalization of feelings goes against the therapeutic approach as expressing and discussing feelings is crucial in the treatment of major depressive disorder. Clients with major depressive disorder often benefit from talking about their emotions and experiences, as it can help in processing their feelings and promoting recovery. Therefore, discouraging verbalization of feelings would hinder the client's progress and is not an appropriate intervention.
5. During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin excess will suggest that the client receive?
- A. Chlorpromazine
- B. Phenelzine
- C. Haloperidol
- D. Olanzapine
Correct answer: D
Rationale: In this scenario, the symptoms of apathy, avolition, and blunted affect are indicative of negative symptoms commonly seen in schizophrenia. These symptoms are often associated with dopamine and serotonin imbalances in the brain. Olanzapine, an atypical antipsychotic, is known for its efficacy in treating both positive and negative symptoms of schizophrenia. It acts by blocking serotonin and dopamine receptors, helping to alleviate the symptoms mentioned. Chlorpromazine and Haloperidol are typical antipsychotics that primarily target dopamine receptors, while Phenelzine is an MAOI used to treat depression and anxiety disorders, not schizophrenia. Therefore, the most appropriate choice for this client displaying these symptoms related to serotonin excess would be Olanzapine.
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