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 has been prescribed sertraline (Zoloft) for depression. Which of the following instructions should the nurse include in the discharge teaching?

Correct answer: B

Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid drinking alcohol while taking sertraline (Zoloft). Alcohol can exacerbate the side effects of the medication, such as drowsiness and dizziness, and may also decrease the effectiveness of the treatment for depression. Choice A is incorrect as sertraline is usually taken in the morning. Choice C is not a specific instruction related to the medication. Choice D is incorrect as abruptly stopping sertraline can lead to withdrawal symptoms and should only be done under medical supervision.

3. A 10-year-old boy breaks his mother's vase while playing. When the mother asks who broke the vase, the little boy says that his sister did it. The little boy is exhibiting which defense mechanism?

Correct answer: A

Rationale: Projection is a defense mechanism where one attributes their own unacceptable thoughts, feelings, or impulses onto another person. In this scenario, the little boy is projecting his actions onto his sister by falsely claiming she broke the vase. Displacement involves transferring emotions from the original source to a substitute target. Dissociation is a disconnection between thoughts, identity, consciousness, and memory. Sublimation is the redirection of unacceptable impulses into socially acceptable activities.

4. After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of a neurocognitive disorder due to dementia. Which statement would cause the nurse to question this diagnosis?

Correct answer: D

Rationale:

5. A client has been prescribed lithium for the treatment of bipolar disorder. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to avoid driving until they know how the medication affects them. Lithium can lead to side effects like dizziness and drowsiness, which could impair one's ability to drive safely. Choice B is incorrect because lithium is usually taken on an empty stomach. Choice C may be true but is not as critical as the potential side effects affecting driving. Choice D is important but not as immediate as ensuring the client's safety while driving.

Similar Questions

When a husband accuses his wife of infidelity, which situation would indicate to the nurse the husband's use of the ego defense mechanism of projection?
April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:
Which of the following are characteristics of borderline personality disorder? Select one that does not apply.
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