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

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?

A. Administer benzodiazepines as prescribed.
B. Monitor the client's vital signs every 4 hours.
C. Provide a high-protein diet.
D. Encourage the client to drink plenty of fluids.

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. Which of the following is an uncommon symptom of schizophrenia?

A. Delusions
B. Fatigue
C. Disorganized speech
D. Catatonia

Correct answer: B

Rationale: Common symptoms of schizophrenia include delusions, hallucinations, disorganized speech, and catatonia. Fatigue is not typically considered a direct symptom of schizophrenia. It is important to focus on symptoms directly related to the disorder when identifying schizophrenia.

3. A patient with obsessive-compulsive disorder (OCD) is performing a ritualistic handwashing routine. What is the nurse's best initial response?

A. Interrupt the ritual to help the patient gain control.
B. Allow the ritual but set limits on the duration.
C. Ignore the behavior to avoid reinforcing it.
D. Encourage the patient to stop the ritual and discuss their feelings.

Correct answer: B

Rationale: In managing a patient with OCD engaging in ritualistic behaviors like handwashing, the nurse's best initial response is to allow the ritual but set limits on the duration. This approach helps in managing the behavior while gradually working towards reducing its frequency. Interrupting the ritual abruptly may cause distress to the patient, ignoring the behavior may reinforce it, and encouraging the patient to stop the ritual without setting limits may not be as effective in the initial stage of intervention.

4. How do psychiatrists determine which diagnosis to give a patient?

A. Psychiatrists use pre-established criteria from the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
B. Hospital policy dictates how psychiatrists diagnose mental disorders.
C. Psychiatrists assess the patient and identify diagnoses based on the patient's symptoms and contributing factors.
D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from.

Correct answer: A

Rationale: Psychiatrists use pre-established criteria from the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to determine which diagnosis to give a patient. The DSM-5 is a comprehensive manual published by the American Psychiatric Association (APA) that outlines specific criteria for diagnosing mental disorders. It aims to ensure accurate and consistent diagnosis and treatment. Choices B and D provide inaccurate information. Hospital policy does not dictate psychiatric diagnoses, and the American Medical Association does not provide diagnostic labels for mental disorders. Choice C, although mentioning the assessment of patients, does not highlight the specific criteria and guidelines provided by the DSM-5 that psychiatrists use to assign diagnoses.

5. When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?

A. Restlessness
B. Rapid heart rate
C. Sweating
D. Dry mouth

Correct answer: B

Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.