ATI RN
ATI Mental Health
1. A client is diagnosed with obsessive-compulsive disorder (OCD), and a nurse is planning care. Which of the following interventions should the nurse exclude from the care plan?
- A. Allowing the client to perform rituals initially
- B. Discouraging the client from washing their hands
- C. Monitoring for suicidal ideation
- D. Providing a structured schedule of activities
Correct answer: C
Rationale: The correct answer is monitoring for suicidal ideation. When caring for a client with OCD, interventions should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Monitoring for suicidal ideation is crucial in assessing the client's safety and mental health status, but it is not a direct intervention specific to managing OCD symptoms.
2. In what significant way should the therapeutic environment differ for a client who has ingested LSD from that of a client who has ingested PCP?
- A. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation. For PCP ingestion, place client on one-on-one intensive supervision.
- B. For LSD ingestion, place the client in restraints. For PCP ingestion, place the client on seizure precautions.
- C. For LSD ingestion, provide continual medieval simulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.
- D. For PCP ingestion, place the client on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.
Correct answer: D
Rationale: When managing a client who has ingested PCP, it is crucial to provide one-on-one intensive supervision to ensure their safety and prevent any harm to themselves or others. This level of supervision is necessary due to the unpredictable and potentially dangerous effects of PCP. On the other hand, for a client who has ingested LSD, it is recommended to maintain a calm environment with limited interaction and minimal verbal stimulation. This approach aims to prevent exacerbating any adverse effects of LSD, such as anxiety or paranoia, by reducing external stimuli. Therefore, the correct approach is to provide one-on-one intensive supervision for PCP ingestion and limit interaction and verbal stimulation for LSD ingestion.
3. After a client with major depressive disorder undergoes electroconvulsive therapy (ECT), which of the following is a priority assessment for the nurse?
- A. Monitoring for signs of infection
- B. Monitoring for signs of respiratory distress
- C. Monitoring for signs of hypotension
- D. Monitoring for signs of bleeding
Correct answer: B
Rationale: The priority assessment for the nurse after a client undergoes electroconvulsive therapy (ECT) is monitoring for signs of respiratory distress. This is crucial due to the potential risk of complications from anesthesia, such as airway compromise or respiratory depression. Prompt identification and intervention in case of respiratory distress are essential to ensure the client's safety and well-being. Monitoring for signs of infection (Choice A) is important but not the priority immediately post-ECT. Hypotension (Choice C) and bleeding (Choice D) are also potential concerns but assessing respiratory distress takes precedence due to the immediate risk it poses to the client's well-being.
4. A client is being taught relaxation techniques to manage anxiety. Which of the following techniques should be included in the teaching? Select one that does not apply.
- A. Deep breathing exercises
- B. Progressive muscle relaxation
- C. Mindfulness meditation
- D. Cognitive restructuring
Correct answer: D
Rationale: Relaxation techniques commonly used to manage anxiety include deep breathing exercises, progressive muscle relaxation, mindfulness meditation, and guided imagery. Cognitive restructuring, on the other hand, is a cognitive-behavioral technique used to challenge and change negative thought patterns, not specifically a relaxation technique. Therefore, choice D, cognitive restructuring, does not apply to relaxation techniques for managing anxiety.
5. A patient with agoraphobia is unable to leave home. Which intervention should the nurse prioritize?
- A. Teach the patient relaxation techniques.
- B. Gradual exposure to feared situations.
- C. Encourage the patient to attend social gatherings.
- D. Provide education about the disorder.
Correct answer: B
Rationale: For a patient with agoraphobia, the priority intervention should be gradual exposure to feared situations. This approach helps the patient confront and gradually overcome their fear of leaving home, a common challenge in agoraphobia. By exposing the patient to feared situations in a step-by-step manner, they can learn to manage their anxiety and increase their confidence in leaving home. Teaching relaxation techniques (Choice A) can be beneficial but may not address the core issue of avoidance behavior. Encouraging the patient to attend social gatherings (Choice C) can be overwhelming and counterproductive at the initial stage of treatment. Providing education about the disorder (Choice D) is important but should come after addressing the immediate need for exposure therapy.
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