a client tells a nurse dont tell anyone but i hid a sharp knife under my mattress in order to protect myself from my roommate who is always threatenin
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Nursing Elites

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ATI Mental Health Proctored Exam 2019

1. A client tells a nurse, 'Don’t tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?

Correct answer: C

Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.

2. A patient with a diagnosis of panic disorder is prescribed an SSRI. Which side effect should the nurse monitor for when the patient starts this medication?

Correct answer: C

Rationale: When a patient with panic disorder is prescribed an SSRI, the nurse should monitor for gastrointestinal disturbances as a common side effect. SSRIs can cause gastrointestinal symptoms such as nausea, diarrhea, or abdominal discomfort, especially at the beginning of treatment. Increased heart rate (Choice A) is not a common side effect of SSRIs; it is more commonly associated with medications like stimulants. Increased appetite (Choice B) is not a typical side effect of SSRIs, as they are more likely to cause weight loss or appetite suppression. Dry mouth (Choice D) is a side effect seen more commonly with medications that have anticholinergic properties, not typically with SSRIs.

3. A patient is receiving education about dietary restrictions while taking a monoamine oxidase inhibitor (MAOI). Which food should the patient avoid?

Correct answer: A

Rationale: Patients taking MAOIs should avoid aged cheese as it contains high levels of tyramine, which can lead to a hypertensive crisis. Monoamine oxidase inhibitors can inhibit the breakdown of tyramine, leading to an excess accumulation in the body and potentially dangerous increases in blood pressure.

4. A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention?

Correct answer: C

Rationale: Establishing rehabilitation programs to decrease the effects of depression is a method of tertiary prevention.

5. A patient diagnosed with dissociative identity disorder has been undergoing therapy for several months. Which outcome indicates that the patient is progressing in therapy?

Correct answer: B

Rationale: In dissociative identity disorder, the merging of different personalities is a crucial indicator of progress in therapy. As the different identities merge, it signifies that the patient is integrating fragmented aspects of their self, leading to a more cohesive sense of identity and a reduction in dissociative symptoms. This process is a significant therapeutic milestone in the treatment of dissociative identity disorder as it promotes internal cohesion and decreases internal conflict. Choices A, C, and D are incorrect because while developing a strong therapeutic relationship, recalling traumatic events without dissociating, and reporting fewer gaps in memory are important aspects of therapy, the merging of different personalities is specifically indicative of substantial progress in treating dissociative identity disorder.

Similar Questions

A patient with panic disorder is prescribed selective serotonin reuptake inhibitors (SSRIs). What should the nurse include in the patient’s education?
When developing a care plan for a patient with generalized anxiety disorder (GAD), which long-term goal is most appropriate?
A patient with schizophrenia is prescribed risperidone. Which statement by the patient indicates understanding of the medication?
What principle should guide a nurse's fear about 'saying the wrong thing' to a patient in nurse-patient communication?
A healthcare professional is assessing a patient with major depressive disorder. Which finding is most concerning?

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