ATI RN
ATI Mental Health Practice B
1. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?
- A. Allow the client to continue the ritualistic behavior initially
- B. Immediately stop the client from performing the ritual
- C. Encourage the client to perform the ritual more quickly
- D. Provide a distraction to interrupt the ritual
Correct answer: A
Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.
2. When educating a client who has a new prescription for Levothyroxine to treat hypothyroidism, which of the following instructions should be included?
- A. Take the medication first thing in the morning before eating.
- B. Take the medication at bedtime to avoid drowsiness.
- C. Take the medication with food to prevent nausea.
- D. Take the medication with a glass of milk.
Correct answer: A
Rationale: Levothyroxine should be taken first thing in the morning before eating to ensure optimal absorption. Taking it on an empty stomach helps prevent interactions with food or other medications that may decrease its effectiveness. It is important to follow this timing recommendation to maintain consistent thyroid hormone levels in the body. Choice B is incorrect as taking Levothyroxine at bedtime may lead to inconsistent absorption and affect its efficacy. Choice C is incorrect because taking Levothyroxine with food can interfere with its absorption. Choice D is incorrect as Levothyroxine should be taken with a full glass of water, not milk, to aid in proper absorption.
3. To prevent recurrent attacks on client with glomerulonephritis, the nurse instructs the client to:
- A. Take a shower instead of tub baths
- B. Avoid situations that involve physical activity
- C. Continue the same restriction on fluid intake
- D. Seek early treatment for respiratory infection
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
- D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Correct answer: The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Rationale:
5. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?
- A. Tell the patient to rest more frequently.
- B. Advise the patient to discontinue digoxin and contact the physician.
- C. Contact the physician, report the symptoms, and request a blood sample to determine the patient's potassium level.
- D. Instruct the patient to avoid caffeine-containing foods.
Correct answer: C
Rationale: The correct action for the nurse to take is to contact the physician, report the patient's symptoms, and request a blood sample to determine the patient's potassium level. Furosemide, a potassium-wasting diuretic, can lead to hypokalemia, causing weakness and palpitations. Therefore, checking the potassium level is crucial in this situation. Simply telling the patient to rest more frequently won't address the underlying issue of potassium depletion. While digoxin can cause adverse effects, in this case, the symptoms are more likely related to furosemide-induced potassium loss. Instructing the patient to avoid caffeine-containing foods may be beneficial in general, but it wouldn't directly address the potassium depletion that needs urgent attention.
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