a nurse is providing care for a client experiencing alcohol withdrawal which intervention should be included in the plan of care
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client is experiencing alcohol withdrawal. Which intervention should be included in the plan of care?

Correct answer: A

Rationale: Administering benzodiazepines as prescribed is a crucial intervention in managing alcohol withdrawal. Benzodiazepines help alleviate symptoms such as anxiety, agitation, and seizures commonly seen in alcohol withdrawal. Monitoring vital signs is important to assess the client's physiological stability, but addressing the withdrawal symptoms with benzodiazepines is a priority to prevent severe complications. Providing a high-protein diet and encouraging fluid intake are important for overall health but do not directly manage alcohol withdrawal symptoms.

2. A client with borderline personality disorder is receiving care. Which of the following interventions should be included in the plan of care?

Correct answer: B

Rationale: When caring for a client with borderline personality disorder, it is essential to encourage independence rather than dependency. This helps promote autonomy and self-reliance, which are important aspects of treatment. Setting clear and consistent boundaries is also crucial, as it provides structure and predictability. Avoiding discussing the client's feelings is not recommended, as addressing emotions and promoting emotional awareness is a key part of therapy. Using a firm, authoritative approach may not be the most effective strategy as it can lead to power struggles and conflicts in individuals with borderline personality disorder.

3. 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.

4. A patient with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse should educate the patient about which potential side effect?

Correct answer: C

Rationale: Corrected Rationale: Selective serotonin reuptake inhibitors (SSRIs) are commonly associated with sexual dysfunction as a side effect. This adverse effect includes decreased libido, delayed orgasm, and erectile dysfunction. Educating patients about this potential side effect is crucial to manage expectations and consider appropriate interventions. Choices A, B, and D are incorrect as SSRIs are not typically associated with hypertension, diarrhea, or weight gain as common side effects.

5. What is the most significant consequence of the excessive use of defense mechanisms?

Correct answer: D

Rationale: The most significant consequence of the excessive use of defense mechanisms is the limitation of problem-solving skills. When individuals rely excessively on defense mechanisms to cope with stress or anxiety, they may avoid addressing underlying issues or seeking healthier coping strategies. This can lead to maladaptive behaviors, hindering their ability to effectively deal with reality, maintain healthy relationships, or perform well in various aspects of life. Choices A, B, and C are incorrect because the suppression of problem-solving skills, intense experience of emotions, and enhancement of learning and growth are not the primary consequences of excessive use of defense mechanisms.

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