ATI RN
ATI Mental Health Proctored Exam 2019
1. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?
- A. Encourage the client to express feelings about the hallucinations.
- B. Distract the client from the hallucinations.
- C. Provide reality-based feedback about the hallucinations.
- D. Encourage the client to ignore the hallucinations.
Correct answer: C
Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.
2. A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?
- A. Assistance with activities of daily living.
- B. Daily physical therapy activities.
- C. Oxygen therapy at 2 liters per nasal cannula.
- D. Complete bedrest with frequent repositioning.
Correct answer: A
Rationale: Class III dyspnea indicates significant limitations in activity due to shortness of breath. Clients with this level of dyspnea should be encouraged to participate in activities within their tolerance levels. Providing assistance with activities of daily living helps conserve energy for essential tasks while promoting independence. Oxygen therapy is only necessary if hypoxia is present, and complete bedrest is generally not recommended for clients with dyspnea unless specifically indicated.
3. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?
- A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
- B. Advance the stronger leg and the cane together to support the weaker leg
- C. Remove the rubber tip when using the cane
- D. Hold the cane on the right side to provide support for the weaker leg
Correct answer: D
Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.
4. A client has been prescribed lorazepam (Ativan) for the treatment of anxiety. Which of the following instructions should the nurse include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid driving until you know how the medication affects you.
- C. Take the medication on an empty stomach.
- D. Double the dose if you miss a dose.
Correct answer: B
Rationale: The correct answer is B because lorazepam (Ativan) can cause dizziness and drowsiness, so the client should avoid driving until they know how the medication affects them. This instruction is crucial for ensuring the client's safety and preventing any potential accidents or harm. Choice A is incorrect because lorazepam does not necessarily need to be taken with food. Choice C is incorrect as it contradicts the usual recommendation of taking lorazepam with or without food. Choice D is incorrect and dangerous advice as doubling the dose of lorazepam can lead to overdose and serious complications.
5. A patient with a history of breast cancer is prescribed tamoxifen (Nolvadex). What critical information should the nurse include in the patient education?
- A. Tamoxifen may increase the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots.
- B. Tamoxifen may cause weight gain, so patients should monitor their diet.
- C. Tamoxifen may decrease the risk of osteoporosis, so patients should ensure adequate calcium intake.
- D. Tamoxifen may cause hot flashes and other menopausal symptoms.
Correct answer: A
Rationale: Tamoxifen increases the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots and the importance of seeking immediate medical attention if they occur.
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