ATI RN
ATI Mental Health Practice B
1. A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?
- A. Administer a prescribed antianxiety medication.
- B. Encourage the client to attend a support group.
- C. Identify triggers of the client's anxiety.
- D. Teach the client deep breathing techniques.
Correct answer: D
Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.
2. A client has a new prescription for Furosemide. Which of the following instructions should be included?
- A. Take this medication at bedtime.
- B. Avoid eating foods high in potassium.
- C. Change positions slowly.
- D. Take this medication with meals.
Correct answer: C
Rationale: Furosemide is a diuretic that can lead to orthostatic hypotension, causing dizziness and falls. Instructing the client to change positions slowly helps prevent these adverse effects by allowing the body to adjust to postural changes gradually, reducing the risk of significant blood pressure drops upon standing up quickly.
3. The nurse cares for a client receiving furosemide (Lasix). The nurse determines that teaching is effective if the client selects which of the following foods?
- A. One medium baked potato
- B. One slice of white bread
- C. One medium apple
- D. One scrambled egg
Correct answer: A
Rationale: The correct answer is A: One medium baked potato. Potatoes are high in potassium, which is crucial for clients on furosemide (Lasix) to prevent hypokalemia, as furosemide can cause potassium loss. White bread (choice B) and scrambled egg (choice D) are not high-potassium foods and do not address the specific need related to furosemide therapy. While apples (choice C) contain some potassium, they are not as rich in potassium as a baked potato, making them a less optimal choice for a client on furosemide.
4. Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?
- A. Increased red blood cell count
- B. Decreased serum ammonia level
- C. Increased protein level
- D. Decreased white blood cell level
Correct answer: B
Rationale: Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.
5. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.
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