a client diagnosed with paranoid schizophrenia states the fbi is watching me i see their agents everywhere which is the nurses most appropriate respon 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. What is the most important action for the nurse to take before administering digoxin to a patient?

Correct answer: A

Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.

3. This is a procedure where a small mesh tube is inserted into an artery to keep it open and improve blood flow.

Correct answer: A

Rationale: Stent placement is a procedure where a small mesh tube (stent) is inserted into an artery to keep it open and improve blood flow, often following angioplasty.

4. A client is prescribed albuterol. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.

5. What is the major effect of filgrastim (Neupogen) in a patient with chronic renal failure?

Correct answer: A

Rationale: The major effect of filgrastim (Neupogen) is to stimulate the production of neutrophils, thereby decreasing neutropenia in patients undergoing chemotherapy. This medication helps the bone marrow produce more white blood cells, specifically neutrophils, to reduce the risk of infections associated with low neutrophil counts. Choices B, C, and D are incorrect because filgrastim does not decrease white blood cells related to infection, growth of blood vessels, or platelet count related to bleeding.

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