ATI NSG 133 Mental health Exam

Correct Answer C: You did nothing to deserve this. You are not to blame.

Explanation:

The nurse's response should be non-judgmental and validate the survivor's feelings while helping to reduce self-blame. The statement, “You did nothing to deserve this. You are not to blame,” is empathetic and reassures the client that the assault is not her fault, which is crucial in helping the client process the trauma. Victims of sexual assault often experience guilt and self-blame, so offering reassurance and helping her understand that the assault was not her fault is a key aspect of trauma-informed care.

Why Other Options Are Wrong:

A) You’re right, it's unsafe to be out at night.

This response reinforces self-blame and shifts the responsibility to the victim. It suggests that the assault was a consequence of the woman’s actions, which can lead to further shame and guilt.

B) Let’s not talk about that now.

Avoiding the discussion or minimizing the woman’s emotional distress is inappropriate. It's important for the nurse to acknowledge her feelings and provide a safe space for her to express them, rather than dismissing her concerns.

D) You should file a police report immediately.

While filing a police report may be part of the process, pressuring the client to take action before she is ready is not appropriate. The nurse should allow the client to make her own decisions about the next steps, providing information about her options and respecting her autonomy. 

Correct Answer A: Keeping a mood journal

Explanation:

Keeping a mood journal is an effective strategy for helping a patient recognize early signs of anger. By tracking their emotions, triggers, and responses over time, the patient can identify patterns and learn to recognize when they are starting to feel angry. This awareness allows them to intervene early, use coping strategies, and prevent anger from escalating into destructive behaviors.

Why Other Options Are Wrong:

B) Avoiding all social contact

Avoiding social contact may seem like a way to prevent anger, but it does not teach the patient to manage their emotions in healthy ways. Social interactions are important for learning conflict resolution and improving emotional regulation. Avoidance could lead to further isolation and frustration.

C) Watching violent films

Watching violent films is not a helpful strategy for recognizing or managing anger. In fact, it may reinforce aggressive behaviors or increase emotional arousal, making it more difficult for the patient to recognize or control anger in a constructive way.

D) Suppressing emotions

Suppressing emotions is not an effective strategy for managing anger. It can lead to emotional buildup and may cause the patient to become more reactive later. Recognizing and addressing emotions early is more effective than bottling them up.

Correct Answer A: Encourage the child to take frequent breaks to release energy.

Explanation of Correct Answer:

Frequent breaks allow children with ADHD to release built-up energy and return to tasks with a clearer focus. This approach is consistent with strategies that help children with ADHD manage their symptoms in school, such as allowing movement and ensuring the child doesn’t become overstimulated or frustrated. It also prevents the child from becoming too overwhelmed or distracted, helping maintain focus during tasks.

Why the Other Options Are Incorrect:

B. Advise the teacher to have the child write an apology for disruptive behavior.

While accountability is important, this intervention does not address the core issue of ADHD—difficulty with attention and impulse control. It may also feel punitive to the child and fail to address their underlying needs related to ADHD.

C. Recommend medication as the first option for managing the child’s behavior.

Medication can be an important treatment option for ADHD, but it is not typically the first step. Behavioral interventions such as regular breaks, structure, and reinforcement of positive behavior should be attempted before considering medication.

D. Ask the teacher to provide more detailed instructions for the child to follow.

While clear instructions are helpful, the child’s difficulty staying seated and focusing is likely more related to the need for breaks and energy release. Providing more instructions does not address the child’s need for movement and physical activity.

Correct Answer B. You will need your blood levels drawn weekly during the first month.

Explanation of Correct Answer:

B. You will need your blood levels drawn weekly during the first month.

Lithium has a narrow therapeutic range, and monitoring blood levels is crucial to avoid toxicity. For the first few weeks of treatment, the nurse should educate the client about the need for regular blood tests to ensure that lithium levels stay within the therapeutic range (0.6 to 1.2 mEq/L). Frequent monitoring is especially important in the early stages to adjust the dosage as needed.

Why the Other Options Are Incorrect:

A. You will need to take this medication on an empty stomach.

This is incorrect because lithium is best taken with food to reduce gastrointestinal upset. Taking it on an empty stomach can increase the likelihood of nausea, vomiting, and stomach irritation.

C. Nausea, vomiting, and diarrhea are not a concern while taking this medication.

This is incorrect because nausea, vomiting, and diarrhea are common early side effects of lithium, especially when starting the medication. These symptoms can also be signs of lithium toxicity, so the client should be instructed to report these symptoms promptly.

D. You should maintain adequate fluid and sodium intake.

This is incorrect because lithium can cause dehydration or changes in sodium levels, which can affect lithium levels. The client should maintain a consistent level of fluid and sodium intake to avoid increasing the risk of toxicity. Excessive fluid or sodium restriction can lead to increased lithium levels, while dehydration can cause toxicity.

Correct Answer A: Cultural conflict

Explanation:

Cultural conflict occurs when an individual is confronted with practices, beliefs, or values that are different from their own, leading to feelings of discomfort or opposition. In this scenario, the nurse is expressing a judgment that the shaman's healing ritual is "a waste of time," reflecting a conflict with the client’s cultural practices.

Why Other Options Are Wrong:

B) Cultural blindness

Cultural blindness refers to ignoring or failing to recognize cultural differences. The nurse in this situation is not ignoring the ritual but rather reacting negatively to it, so this is not cultural blindness.

C) Stereotyping

Stereotyping involves making generalized assumptions about individuals or groups based on preconceived notions, often in a negative manner. While the nurse may have negative feelings about the ritual, the situation does not demonstrate stereotyping, as the nurse is not making a broad assumption about a group of people.

D) Cultural shock

Cultural shock occurs when an individual experiences significant discomfort or disorientation when exposed to a radically different culture. While the nurse is uncomfortable with the ritual, cultural shock typically involves a deeper sense of confusion or disorientation, often experienced by those who are in a completely foreign environment. This situation more closely aligns with cultural conflict.

Correct Answer:

A) Somatic delusions

C) Gustatory hallucinations

E) Clang associations

Explanation:

Risperidone (Risperdal) is an atypical antipsychotic that helps manage both positive symptoms (e.g., delusions and hallucinations) and negative symptoms (e.g., emotional blunting) of schizophrenia. It primarily works by blocking dopamine and serotonin receptors in the brain.

A) Somatic delusions: Risperidone is effective in addressing delusions, including somatic delusions (false beliefs about one’s body or health), which are common positive symptoms in schizophrenia.

C) Gustatory hallucinations: Risperidone is effective in treating auditory, visual, and gustatory hallucinations, which are also positive symptoms of schizophrenia.

E) Clang associations: These are disorganized thought patterns, which may involve using words based on sound rather than meaning. Risperidone can help alleviate disorganized thinking and speech, including clang associations.

Why Other Options Are Wrong:

B) Social isolation:

Social isolation is a negative symptom of schizophrenia, which is often related to emotional withdrawal and lack of motivation. While Risperidone can help reduce psychotic symptoms, it is less effective at directly addressing negative symptoms like social isolation. A comprehensive treatment plan that includes psychosocial interventions is more likely to address isolation.

D) Flat affect:

A flat affect, or lack of emotional expression, is a negative symptom of schizophrenia. Risperidone may have a modest effect on improving emotional responsiveness, but it is not the most effective medication for addressing negative symptoms like flat affect. Other interventions, such as therapy, are often needed for these symptoms.

Correct Answer C: Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.

Explanation:

As individuals age, the bladder’s ability to contract effectively diminishes, leading to urine retention and stasis. This means urine remains in the bladder for extended periods, which can increase the risk of urinary tract infections (UTIs) due to bacterial growth. This reduced contractility is a common age-related change in urinary function.

Why Other Options Are Wrong:

A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection.

This statement is partially true in that aging can affect the kidneys' ability to concentrate urine. However, this directly leads to dehydration and electrolyte imbalances rather than UTIs. UTIs are more closely linked to urine retention and stasis in the bladder rather than kidney concentration issues.

B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency.

This is inaccurate. As individuals age, bladder muscle tone typically decreases rather than increases, which can lead to reduced bladder capacity and incontinence. Increased muscle tone would usually result in a higher capacity to hold urine, not reduced capacity.

D) Neuromuscular problems may result in the patient finding urinary control too much trouble, resulting in incontinence.

Neuromuscular issues can indeed lead to incontinence, but this is not the most common effect of aging in relation to urinary assessment. The more significant issue for elderly patients is often decreased bladder contractility, not neuromuscular problems affecting urinary control

Correct Answer A: Check for residual content using a piston syringe.

Explanation:

Before administering a feeding through a feeding tube, it is essential to check for residual content using a piston syringe. This step ensures the stomach is not overloaded with previously ingested content and helps prevent complications like aspiration or discomfort.

Why Other Options Are Wrong:

B) Flush the feeding tube with 30 mL of water.

While flushing the tube with water is a good practice to prevent clogging and ensure patency, it is not the primary safety procedure to check for residual content, which is more critical prior to feeding.

C) Verify the patient's identity using two identifiers.

Verifying patient identity is an important safety procedure in any medical intervention, but it is not specific to feeding tube administration. The focus before administering a feeding is on checking residual content to prevent complications.

D) Administer the feeding at room temperature without checking the tube placement.

Checking the tube placement is essential to ensure that the tube is properly positioned in the stomach or intestines before feeding. Administering a feeding without confirming tube placement can result in aspiration or improper feeding.

Correct Answer A. Grandiosity

Explanation of Correct Answer:

A. Grandiosity

The client’s statement reflects grandiosity, which is a common symptom of mania in bipolar disorder. Grandiosity is characterized by an inflated sense of self-importance, abilities, or powers. The client believes they are capable of extraordinary things, such as flying home or becoming a U.S. Senator, which exceeds realistic expectations and indicates an exaggerated sense of self.

Why the Other Options Are Incorrect:

B. Flight of ideas

Flight of ideas refers to a rapid flow of thoughts where the individual shifts from one topic to another quickly, often without clear connections. Although the client’s speech is grandiose, it does not indicate a rapid, disjointed pattern of thinking that would be typical of flight of ideas.

C. Derealization

Derealization is a feeling of detachment or unreality regarding the environment, where the world seems strange or unreal. The client’s statement about feeling like Superman does not reflect a sense of disconnection from the environment, so derealization is not the correct term here.

D. Reality testing

Reality testing involves the ability to distinguish between what is real and what is not. The client’s grandiose beliefs indicate a lack of accurate reality testing rather than an intact ability to distinguish between reality and delusion. This would fall under delusion or impaired reality testing, not the term "reality testing" itself.