at what point should the nurse determine that a client is at risk for developing a mental disorder
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2023 Quizlet

1. At what point should the nurse determine that a client is at risk for developing a mental disorder?

Correct answer: B

Rationale: The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client's ability to communicate distress would be considered a positive attribute.

2. A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient are common initial biological responses to stress? Select one that doesn't apply.

Correct answer: C

Rationale: When faced with stress, the body can react in various ways. Symptoms such as constricted pupils, increased heart rate, and increased respirations are commonly seen as initial biological responses to stress. In this case, the presence of constricted pupils is not typically associated with stress responses. Dilated pupils are more commonly linked to the Fight or Flight response. Watery eyes and increased heart rate are typical responses to stress. Unusual food cravings are not considered a typical biological response to stress.

3. A client diagnosed with major depressive disorder is prescribed an SSRI. Which side effect should the nurse monitor for in the initial weeks of treatment?

Correct answer: B

Rationale: When a client is prescribed an SSRI for major depressive disorder, the nurse should closely monitor for an increased risk of suicide, especially in younger patients, during the initial weeks of treatment. SSRIs may initially increase energy levels before improving mood, which can lead to a higher risk of suicide in some individuals. Weight loss is not a common side effect of SSRIs and may actually be a concern for some patients with major depressive disorder who experience appetite changes. Hypertension is not typically associated with SSRIs, and photosensitivity is not a common side effect of this class of medications.

4. During an acute panic attack, which intervention should the nurse implement?

Correct answer: C

Rationale: During an acute panic attack, the priority intervention is to create a calm and safe environment. Teaching the client deep breathing exercises is crucial as it promotes relaxation and reduces hyperventilation, helping to manage the panic attack effectively. Encouraging the client to discuss their feelings may exacerbate the panic by increasing emotional distress. Providing a busy environment can escalate stress levels rather than alleviate them. Leaving the client alone may lead to feelings of abandonment or worsen the panic attack. Therefore, the most appropriate intervention is to teach deep breathing exercises to help the client regain control and manage the panic attack.

5. A client with generalized anxiety disorder (GAD) is being discharged. Which of the following instructions should the nurse not include in the discharge teaching?

Correct answer: D

Rationale: Discharge instructions for a client with GAD should include practicing relaxation techniques daily, avoiding caffeine and alcohol, engaging in regular physical activity, and seeking support from friends and family. Benzodiazepines are not recommended as the first-line treatment due to their potential for dependence and should not be included in the discharge teaching.

Similar Questions

A nurse is providing education to the family of a client who has been diagnosed with major depressive disorder. Which of the following instructions should the nurse include?
A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects shouldn't the nurse monitor for?
Which of the following interventions is most appropriate for a client experiencing severe anxiety?
Which of the following is a common side effect of benzodiazepines prescribed for anxiety?
Which therapeutic approach is most effective for managing borderline personality disorder?

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