a nurse has just admitted a client who has been diagnosed with major depressive disorder which of the following interventions should the nurse impleme
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. Upon admission, a client diagnosed with major depressive disorder needs the nurse to implement which of the following interventions first?

Correct answer: B

Rationale: The initial intervention the nurse should prioritize is to establish a trusting relationship with the client. Building trust is fundamental in fostering effective therapeutic communication and providing quality care. This foundational step lays the groundwork for further assessment, collaboration on care plans, and promoting treatment adherence. Administering medication or discussing compliance should come after the establishment of trust to ensure the client feels supported and understood.

2. During cognitive-behavioral therapy, a 12-year-old patient reports to the nurse practitioner:

Correct answer: B

Rationale: In cognitive-behavioral therapy, recognizing and challenging negative thoughts is crucial for progress. Choice B demonstrates the patient's ability to identify and correct distorted thoughts, indicating positive advancement in therapy. This cognitive restructuring is a key component of cognitive-behavioral therapy, helping individuals develop healthier thinking patterns and coping strategies.

3. Which of the following statements about the DSM-5 is inaccurate?

Correct answer: D

Rationale: The DSM-5 is a diagnostic tool that provides specific criteria for diagnosing mental disorders, is utilized by mental health professionals to guide diagnosis, and offers a systematic classification of mental disorders. The statement that the DSM-5 includes guidelines for the treatment of mental disorders is inaccurate. The primary focus of the DSM-5 is on diagnosis and classification, not treatment. Therefore, choice D is the correct answer. Choices A, B, and C accurately describe the purpose and functions of the DSM-5.

4. A client has been prescribed sertraline for depression, and the nurse is providing discharge instructions. Which dietary instruction should the nurse include?

Correct answer: C

Rationale: Clients prescribed sertraline should avoid foods high in tyramine to prevent a hypertensive crisis. Sertraline, an antidepressant belonging to the selective serotonin reuptake inhibitor (SSRI) class, can interact with tyramine-rich foods, potentially causing a dangerous increase in blood pressure known as a hypertensive crisis. Choices A, B, and D are incorrect because there is no specific dietary restriction related to sodium, calcium, or potassium intake when taking sertraline.

5. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select one that does not apply.

Correct answer: C

Rationale: The patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.

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