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. Which client statement should alert a nurse that a client may be responding maladaptively to stress?

Correct answer: A

Rationale: The correct answer is A. Reliance on social isolation as a coping mechanism is maladaptive and can hinder the development of appropriate coping skills and access to support systems. It may indicate a lack of healthy coping strategies and social connections, which are important for managing stress effectively. Choice B is a positive coping strategy that promotes self-reflection and emotional expression. Choice C reflects a proactive approach to managing stress through physical activity. Choice D shows a willingness to seek professional help, which is a healthy coping mechanism.

3. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?

Correct answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.

4. During the assessment of an adolescent who collapsed during Olympic figure skating training and was diagnosed with severe malnutrition due to anorexia nervosa, which client statement supports the use of a family-based approach?

Correct answer: B

Rationale: The statement 'I'm tired of fighting with my parents about eating' indicates a struggle related to food and parental conflicts, suggesting family dynamics play a role in the client's eating disorder. In cases of anorexia nervosa in adolescents, involving the family in the treatment process through a family-based approach has shown to be effective. This approach recognizes the influence of family interactions on the development and maintenance of eating disorders, aiming to improve communication, support, and understanding within the family unit to facilitate recovery.

5. A client with borderline personality disorder exhibits self-mutilating behavior. Which nursing intervention should the nurse implement to address this behavior?

Correct answer: C

Rationale: The correct intervention when dealing with a client exhibiting self-mutilating behavior, especially with borderline personality disorder, is to provide a safe environment to prevent self-harm. This approach is crucial in ensuring the client's physical safety and well-being. Setting firm limits may be appropriate in some situations, but the immediate priority is to prevent self-harm. Encouraging the client to discuss underlying issues and discussing consequences are important aspects of therapy; however, in the case of acute self-mutilating behavior, the primary focus should be on creating a safe environment to prevent harm.

Similar Questions

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When an individual's stress response is sustained over a long period of time, which physiological effect of the endocrine system should one anticipate?
A client with a history of alcohol use disorder is admitted to the hospital. Which assessment finding would indicate early alcohol withdrawal?
A client experiencing a manic episode is talking rapidly and jumping from one topic to another. Which term describes this symptom?

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