a woman was abducted and raped at gunpoint by an unknown assailant when found she was confused and disoriented the nurse makes the following observati
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2023

1. A woman was abducted and raped at gunpoint by an unknown assailant. When found, she was confused and disoriented. The nurse makes the following observations about the client. She is talking rapidly in disjointed phrases, is unable to concentrate, and is indecisive when asked to make simple decisions. The client's level of anxiety can be assessed as

Correct answer: B

Rationale: The client's presentation, including rapid and disjointed speech, inability to concentrate, and indecisiveness, are indicative of severe anxiety. These symptoms suggest a high level of distress and impairment in cognitive functioning, which aligns with severe anxiety rather than mild or moderate levels. The traumatic experience of being abducted and raped at gunpoint would likely contribute to such a severe level of anxiety.

2. When assessing a client diagnosed with major depressive disorder who states, 'I feel like I can't go on,' which of the following actions should the nurse take first?

Correct answer: B

Rationale: The priority action for the nurse is to assess the client's risk for suicide. By asking if the client has a plan to commit suicide, the nurse can determine the immediate safety of the client and take appropriate interventions to prevent harm. Administering antidepressant medication is not the first action to take in this situation as assessing the client's safety is the priority. Encouraging the client to attend a support group or contacting the client's family, although beneficial, are not immediate actions to ensure the client's safety in a crisis situation.

3. When a patient with major depressive disorder is prescribed escitalopram, what potential side effect should the healthcare provider educate the patient about?

Correct answer: B

Rationale: The correct answer is B: Insomnia. Escitalopram, a selective serotonin reuptake inhibitor (SSRI), commonly causes insomnia as a side effect. Patients should be informed about the possibility of experiencing difficulty falling or staying asleep when starting this medication. Choices A, C, and D are incorrect because weight gain, diarrhea, and hypertension are not typically associated with escitalopram use.

4. Based on what criteria do most cultures label behavior as mental illness?

Correct answer: A

Rationale: The correct answer is A: Incomprehensibility and cultural relativity. Incomprehensibility and cultural relativity are the main criteria used across cultures to define behavior as mental illness. When behavior is incomprehensible and significantly deviates from cultural norms, it is more likely to be classified as a mental illness. Choices B, C, and D are incorrect. Strength of character, ethics, goal directedness, high energy, creativity, and good coping skills are typically associated with positive mental health rather than mental illness.

5. A patient with obsessive-compulsive disorder (OCD) is prescribed paroxetine. The nurse should educate the patient about which potential side effect?

Correct answer: C

Rationale: The correct answer is C, 'Sexual dysfunction.' Paroxetine, an SSRI commonly prescribed for OCD, can lead to sexual dysfunction as a side effect. Patients should be educated about this potential adverse effect to ensure they are aware and can seek appropriate management if needed. Choices A, B, and D are incorrect because insomnia, weight loss, and hypertension are not typically associated with paroxetine use as common side effects in patients with OCD.

Similar Questions

Which client statement should alert a nurse that a client may be responding maladaptively to stress?
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?
A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse include in the plan of care?
A client with bipolar disorder is experiencing a depressive episode. Which nursing intervention is most appropriate?
A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse implement? Select one that does not apply.

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