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?
- A. Administer benzodiazepines as prescribed.
- B. Monitor the client's vital signs every 4 hours.
- C. Provide a high-protein diet.
- D. Encourage the client to drink plenty of fluids.
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 with obsessive-compulsive disorder (OCD) spends several hours each day washing her hands. Which intervention should the nurse implement?
- A. Encourage the client to wash her hands less frequently.
- B. Set a time limit for hand washing.
- C. Teach the client relaxation techniques.
- D. Discourage the client from washing her hands.
Correct answer: B
Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.
3. A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?
- A. Allow the client to pace in a safe environment.
- B. Encourage the client to discuss feelings.
- C. Help the client identify the cause of anxiety.
- D. Provide a distraction for the client.
Correct answer: A
Rationale: Allowing the client to pace in a safe environment is an appropriate nursing intervention for managing moderate anxiety levels. Allowing pacing provides the client with a physical outlet for their anxiety and can help them release nervous energy without increasing distress. It promotes movement and can aid in reducing feelings of restlessness or agitation. Encouraging the client to discuss feelings (Choice B) is more suitable for addressing emotional aspects of anxiety rather than providing an immediate physical outlet. Helping the client identify the cause of anxiety (Choice C) may be more appropriate for long-term management but may not address the immediate need for physical release. Providing a distraction (Choice D) may not directly address the physical needs associated with moderate anxiety levels.
4. A client with bipolar disorder is in the manic phase. Which nursing intervention should the nurse implement to ensure the client's safety?
- A. Provide a structured environment with minimal stimuli.
- B. Encourage the client to participate in group activities.
- C. Monitor the client closely for signs of exhaustion.
- D. Encourage the client to rest and sleep as needed.
Correct answer: A
Rationale: During the manic phase of bipolar disorder, individuals may engage in impulsive behaviors that can put them at risk of harm. Providing a structured environment with minimal stimuli can help reduce the risk of injury by minimizing triggers for impulsive actions. This intervention promotes a safe and controlled setting for the client, which is crucial in managing the symptoms of mania. Encouraging the client to participate in group activities (Choice B) may increase stimuli and potentially exacerbate manic symptoms. Monitoring for signs of exhaustion (Choice C) is important but does not directly address the safety concerns related to impulsive behaviors during mania. Encouraging the client to rest and sleep as needed (Choice D) may be challenging during the manic phase when individuals typically experience decreased need for sleep.
5. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?
- A. Encourage the client to discuss the voices.
- B. Instruct the client to listen to music to drown out the voices.
- C. Tell the client that the voices are not real.
- D. Distract the client from the voices.
Correct answer: A
Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia. Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.
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