a client has been taking lithium for several years with good symptom control the client presents in the emergency department with blurred vision tinni
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam

1. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms?

Correct answer: B

Rationale: Symptoms such as blurred vision, tinnitus, and severe diarrhea are indicative of lithium toxicity. A lithium level of 1.7 is within the toxic range. When clients present with these symptoms, it is crucial for the nurse to correlate them with elevated lithium levels to ensure timely intervention and prevent further complications.

2. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?

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.

3. An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?

Correct answer: C

Rationale: In situations where a client is experiencing severe anxiety and struggles with independent problem-solving, it is essential for the nurse to work through the problem-solving process together with the client. By doing so, the nurse can provide support and guidance to help the client navigate through their challenges effectively. Choice A is not the most appropriate as just encouraging alternative coping mechanisms may not address the root of the problem. Choice B of completing the problem-solving process for the graduate does not promote independence or skill development. Choice D of encouraging the graduate to keep a journal may be helpful but does not directly address the need for assistance in problem-solving during heightened anxiety.

4. A nurse is providing discharge instructions to a client who has been prescribed fluoxetine (Prozac). Which information should the nurse include?

Correct answer: B

Rationale: Clients taking fluoxetine (Prozac) should avoid alcohol to prevent adverse interactions.

5. During a routine health screening, a grieving widow whose husband died 15 months ago reports emptiness, a loss of self, difficulty thinking of the future, and anger at her dead husband. The nurse suggests bereavement counseling. The widow is most likely suffering from:

Correct answer: C

Rationale: The widow's symptoms align more closely with an adjustment disorder rather than major depression, normal grieving, or posttraumatic stress disorder. The widow's prolonged struggle in coping with the loss, characterized by emptiness, loss of self, difficulty envisioning the future, and anger towards her deceased husband, indicates an inability to adapt to the loss. These symptoms are indicative of an adjustment disorder, which typically arises in response to a significant life stressor and persists beyond what is considered a normal grieving process. Bereavement counseling can help the widow navigate her emotions and coping strategies during this challenging period.

Similar Questions

A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement to address this symptom?
A client has been prescribed lorazepam (Ativan) for the treatment of anxiety. Which of the following instructions should the nurse include?
A patient with posttraumatic stress disorder (PTSD) is prescribed prazosin. The nurse understands that this medication is used to treat which symptom of PTSD?
A client is diagnosed with obsessive-compulsive disorder (OCD), and a nurse is planning care. Which of the following interventions should the nurse exclude from the care plan?
A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, 'I work hard to provide for my family. I don't see why I can't drink to relax.' The nurse recognizes the use of which defense mechanism?

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