a nurse is caring for a client who is experiencing alcohol withdrawal which symptom should the nurse identify as a priority to address
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?

Correct answer: C

Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.

2. A client has been diagnosed with borderline personality disorder, and a nurse is providing care. Which intervention should the nurse implement to promote the client's safety?

Correct answer: A

Rationale: Implementing a no-harm contract is a crucial intervention for clients with borderline personality disorder as it helps establish an agreement between the client and the healthcare provider to abstain from self-harming behaviors. This contract aims to promote the client's safety by enhancing awareness and providing a structured approach in managing impulses and emotions.

3. A nurse is assessing a client who has been diagnosed with persistent depressive disorder (dysthymia). Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct finding the nurse should expect in a client diagnosed with persistent depressive disorder (dysthymia) is a lack of interest in activities. This disorder is characterized by a chronic depressive mood lasting for at least two years, alongside symptoms such as changes in appetite, fatigue, low self-esteem, and difficulty concentrating. Clients with dysthymia do not typically experience hypomania, periods of elevated mood, or feelings of detachment from one's body, which are more commonly associated with other mood disorders. Therefore, options A, B, and D are incorrect findings for a client with persistent depressive disorder.

4. A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?

Correct answer: B

Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.

5. Which of the following are common symptoms of schizophrenia? Select one that does not apply.

Correct answer: C

Rationale: Common symptoms of schizophrenia include delusions, hallucinations, disorganized speech, and catatonia. Organized speech is not a typical symptom of schizophrenia. In schizophrenia, individuals often exhibit disorganized or incoherent speech patterns, rather than organized speech. Euphoria is not typically associated with schizophrenia, making it an incorrect choice.

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