a client states i am the only one who can hear voices which is the nurses best response
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

Correct answer: A

Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.

2. A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?

Correct answer: C

Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.

3. A nurse is providing education to a client who has been prescribed lithium for bipolar disorder. Which statement by the client indicates an accurate understanding of the medication?

Correct answer: B

Rationale: Clients taking lithium should maintain a consistent sodium intake to avoid fluctuations in lithium levels.

4. When interviewing a distressed client who was fired after 15 years of loyal employment, which of the following questions would best assist the nurse in determining the client's appraisal of the situation? Select the one that does not apply.

Correct answer: C

Rationale: In this scenario, it is crucial for the nurse to help the client assess their coping mechanisms and perspective on the situation. Questions A and B focus on exploring the client's coping resources and past experiences to guide them towards effective stress management. Asking who is to blame (choice C) is not conducive to evaluating coping abilities; instead, it might elicit a blame-focused response, which can impede progress. Choice D, inquiring about the reason for being fired, is a nontherapeutic approach that does not promote a constructive appraisal of the situation.

5. A client has been prescribed escitalopram (Lexapro) for depression. Which instruction should the nurse include in the discharge teaching?

Correct answer: B

Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid consuming alcohol while taking escitalopram (Lexapro). Alcohol can potentiate side effects such as drowsiness and dizziness when combined with this medication. Choice A is incorrect because escitalopram is usually taken in the morning due to its potential to cause insomnia if taken at bedtime. Choice C is incorrect because taking the medication with or without food does not significantly affect its absorption or side effects. Choice D is incorrect because it is essential for the client to continue taking the medication even if they start feeling better, as abruptly stopping an antidepressant can lead to withdrawal symptoms and a relapse of depression.

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