a nurse is caring for a client who has been diagnosed with borderline personality disorder the client has been admitted to the psychiatric unit after
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.

2. In a center for women who have been abused, which intervention would the nurse use for a woman whose husband has been abusing her for several years?

Correct answer: C

Rationale: Choice C is the most appropriate intervention when working with a woman who has been abused by her husband. It acknowledges the woman's pain, expresses empathy, and offers support, creating a safe space for her to open up and seek help. This response shows understanding and compassion, which are crucial when dealing with individuals experiencing abuse.

3. A patient with social anxiety disorder is prescribed propranolol. The nurse understands that this medication is used primarily to:

Correct answer: A

Rationale: The correct answer is A: Reduce anxiety symptoms. Propranolol, a beta-blocker, is primarily used to reduce physical symptoms of anxiety, such as rapid heartbeat and trembling, in patients with social anxiety disorder. It does not directly affect mood, energy levels, or social interactions. Choice B is incorrect because propranolol does not target mood improvement. Choice C is incorrect because propranolol does not aim to increase energy levels. Choice D is incorrect because propranolol does not enhance social interactions; its primary role is in reducing physical symptoms of anxiety.

4. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?

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.

5. A client has been prescribed fluoxetine (Prozac) for the treatment of depression. Which of the following instructions should the nurse include in the discharge instructions?

Correct answer: B

Rationale: The correct answer is B. The nurse should instruct the client to avoid drinking alcohol while taking fluoxetine (Prozac) because alcohol can increase the risk of side effects such as drowsiness and dizziness. It is important to follow this instruction to ensure the safe and effective use of the medication in the treatment of depression. Choice A is incorrect because fluoxetine (Prozac) is usually taken in the morning to prevent insomnia. Choice C is not a crucial instruction for this medication. Choice D is incorrect as abruptly stopping fluoxetine can lead to withdrawal symptoms and should only be done under medical supervision.

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