a client diagnosed with paranoid schizophrenia states the fbi is watching me i see their agents everywhere which is the nurses most appropriate respon
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. 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?

Correct answer: B

Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.

2. A client has been prescribed a monoamine oxidase inhibitor (MAOI). Which dietary restriction should the nurse emphasize during discharge instructions?

Correct answer: C

Rationale: The correct answer is C: Avoid foods high in tyramine. Clients taking MAOIs should avoid foods high in tyramine to prevent hypertensive crisis. Tyramine is found in aged, fermented, or spoiled foods. Choices A, B, and D are incorrect because potassium, calcium, and sodium restrictions are not specifically required for clients taking MAOIs.

3. When a patient with major depressive disorder is started on fluoxetine, what is the most important side effect for the nurse to monitor?

Correct answer: B

Rationale: When initiating fluoxetine therapy in a patient with major depressive disorder, monitoring for suicidal ideation is crucial due to the increased risk of suicidal thoughts or behaviors that can occur, especially in the initial phase of treatment. This close monitoring is essential to ensure patient safety and intervene promptly if such symptoms arise. Weight gain, hypertension, and hyperglycemia are potential side effects of some medications used to treat depression, but suicidal ideation is the most critical and immediate side effect to monitor for when starting fluoxetine.

4. A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that does not apply.

Correct answer: C

Rationale: The correct answer is C, 'Mindfulness meditation.' Side effects of antipsychotic medications include tardive dyskinesia, neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia. Mindfulness meditation is not a side effect of antipsychotic medications. Choices A, B, and D are all potential side effects of antipsychotic medications. Tardive dyskinesia is a movement disorder characterized by repetitive, involuntary movements. Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medication. Hyperglycemia can occur as a side effect of some antipsychotic medications, particularly the second-generation ones.

5. When explaining suicide precautions to a client, what would be the best explanation?

Correct answer: D

Rationale: Choice D provides a supportive and empowering explanation to the client on suicide precautions. It emphasizes the client's own sense of safety and control, indicating that the observation is temporary and can be removed when the client feels safer. This approach promotes autonomy and encourages the client to actively participate in their own well-being, fostering a therapeutic relationship based on trust and collaboration.

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