ATI RN
ATI Mental Health Practice B
1. A psychiatric nurse observes that a client diagnosed with schizophrenia is pacing up and down the corridor. The client is muttering to himself, and his hands are trembling. Which of the following actions should the nurse take first?
- A. Ask the client if he is hearing voices.
- B. Offer the client a PRN medication for anxiety.
- C. Encourage the client to participate in a relaxation exercise.
- D. Remove the client to a quieter environment.
Correct answer: D
Rationale: The first action the nurse should take is to remove the client to a quieter environment. This intervention aims to reduce stimuli that may be contributing to the client's agitation and help create a calmer and more supportive setting for the client. Choices A, B, and C are not the priority in this situation as addressing the environmental factors should come first before exploring symptoms, offering medication, or engaging in relaxation exercises.
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 is an uncommon initial biological response to stress?
- A. Constricted pupils
- B. Watery eyes
- C. Palpitations
- D. Increased heart rate
Correct answer: A
Rationale: Increased lacrimal secretions, palpitations, and increased heart rate are common initial biological responses to stress. Constricted pupils are not typical in the initial response to stress and are more associated with the opposite response, the Rest and Digest system. Watery eyes, palpitations, and increased heart rate are indicative of the body's fight or flight response to stress. Unusual food cravings are not a typical biological response to stress.
3. A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?
- A. Weight gain and increased appetite
- B. Lanugo on the face and back
- C. Increased body temperature and tachycardia
- D. Hyperactivity and distractibility
Correct answer: B
Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.
4. A healthcare professional is providing education to the family of a client who has been diagnosed with schizophrenia. Which of the following instructions should the healthcare professional include?
- A. Encourage the client to participate in daily activities.
- B. Encourage the client to express their feelings.
- C. Encourage the client to avoid caffeine.
- D. Encourage the client to spend time alone.
Correct answer: A
Rationale: Encouraging the client to participate in daily activities is crucial in managing schizophrenia. Engaging in activities can enhance the quality of life and reduce symptoms by providing structure, routine, and social interaction, which are beneficial for individuals with schizophrenia. Choices B, C, and D are not the most appropriate instructions for managing schizophrenia. While expressing feelings can be helpful, daily activities have a more significant impact on managing the condition. Avoiding caffeine and spending time alone are not directly related to managing schizophrenia and may not be the most beneficial strategies.
5. 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.
- A. Encourage participation in activities
- B. Promote adequate nutrition and hydration
- C. Monitor for suicidal ideation
- D. Discourage verbalization of feelings
Correct answer: D
Rationale: Interventions for a client with bipolar disorder experiencing a depressive episode include encouraging participation in activities, promoting adequate nutrition and hydration, monitoring for suicidal ideation, and providing a structured daily schedule. Discussing feelings is an essential part of therapy for clients with bipolar disorder, thus discouraging verbalization of feelings is not therapeutic and should not be implemented. Choice D is incorrect because it goes against the principles of therapeutic communication and emotional expression, which are crucial in managing bipolar disorder.
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