ATI NSG 133 Mental health Exam

Correct Answers:

B. Auditory hallucinations

D. Anxiety

E. Delusions

F. Insomnia

Explanation of Correct Answers:

B. Auditory hallucinations: Hallucinations, including auditory ones, are a significant sign of alcohol withdrawal and can be indicative of alcohol use disorder or delirium tremens (DTs), a severe form of withdrawal. Hearing voices is a serious symptom that should be addressed immediately.

D. Anxiety: Anxiety is a common symptom of alcohol use disorder, particularly during withdrawal. The client’s anxiety, irritability, and sleep disturbances are consistent with alcohol withdrawal symptoms.

E. Delusions: Delusions (e.g., feeling disconnected from reality) can occur during alcohol withdrawal or in the context of alcohol use disorder. This could indicate a more severe withdrawal state like delirium tremens.

F. Insomnia: Difficulty sleeping (insomnia) is another common symptom associated with alcohol use disorder and withdrawal. Sleep disturbances can be part of the acute withdrawal syndrome.

Why the Other Options Are Incorrect:

A. Elevated mood: Elevated mood is generally not a typical symptom of alcohol use disorder or withdrawal. This may occur with bipolar disorder or other conditions but is not commonly associated with alcohol use disorder, particularly during withdrawal.

C. Increased appetite: Increased appetite is not typically associated with alcohol use disorder or withdrawal. In fact, some individuals may experience loss of appetite or other gastrointestinal disturbances during withdrawal.

Correct Answer D: Values clarification

Explanation:

Values clarification is a process by which individuals explore and understand their own values, helping them make decisions that align with their goals and beliefs. In this case, by helping the patient clarify what is important to him—such as health and quality of life—the nurse can guide him toward making healthier lifestyle changes, such as quitting smoking, eating better, and exercising.

Why Other Options Are Wrong:

A) Ethical change strategy

This term is not commonly used in nursing practice as a specific method for behavior change. While ethical considerations are important, this is not a targeted strategy for helping someone change their behavior in this context.

B) Values neutrality choices

Values neutrality refers to the concept of not imposing one's own values on others. While this is important in maintaining an unbiased and non-judgmental approach, it does not specifically focus on helping the patient clarify and act on his values to make behavior changes.

C) Values transmission

Values transmission refers to teaching or passing on values to others, but it does not directly involve the individual exploring and making their own choices. In this case, the goal is to help the patient come to his own understanding and decision about his lifestyle, which is what values clarification achieves.

Correct Answer B: Remove stimuli and speak calmly

Explanation:

The priority action when a patient with dementia exhibits aggressive behaviors like throwing objects is to remove stimuli (such as loud noises or crowding) and speak calmly to the patient. This helps to reduce agitation and de-escalate the situation. A calm and non-confrontational approach is essential in managing aggression in patients with dementia, and creating a safe, quiet environment can often help the patient regain control.

Why Other Options Are Wrong:

A) Restrain the patient

Restraint should only be used as a last resort and only when the patient is at imminent risk of harming themselves or others. Restraints can lead to physical and emotional harm, so they should not be the first step in responding to aggression.

C) Yell to get attention

Yelling can escalate the agitation and fear of a patient with dementia, further increasing aggression. It is important to use a calm and reassuring tone to help the patient feel safe and understood.

D) Leave the patient alone

While it might seem that giving the patient space is an option, isolation can increase feelings of anxiety and frustration in a patient with dementia. It's important to approach the patient in a calm, supportive way, rather than leaving them alone in an agitated state.

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 C: It’s okay to feel afraid, but eating is a necessary step for recovery.

Explanation of Correct Answer:

This response is empathetic and acknowledges the patient's fear, which is central to the experience of someone with anorexia nervosa. It normalizes the patient's feelings of fear while reinforcing the importance of eating for recovery. It is compassionate and non-judgmental, which builds rapport and encourages the patient to work toward recovery without feeling pressured or blamed.

Why the Other Options Are Incorrect:

A. You need to eat in order to be healthy, and I’m here to help you with that.

While this response is well-meaning, it may come off as directive or dismissive of the patient’s emotions. It lacks empathy and doesn’t address the patient’s fear, which is a significant barrier to recovery.

B. Eating can be hard, but you have to start trying to eat regularly.

This statement could be seen as oversimplifying the patient’s struggle. Anorexia nervosa is a complex mental health disorder, and this response doesn't acknowledge the depth of the patient’s emotional and psychological fears regarding food and body image.

D. If you don’t start eating, we will need to consider a feeding tube.

This is a threatening response and can heighten the patient's anxiety. Threats can lead to feelings of shame or resistance, making the patient less likely to engage in treatment. It’s essential to approach anorexia nervosa with a supportive and non-coercive attitude.

 Correct Answer C: Electrolyte imbalance

Explanation:

The most immediate concern in a patient with anorexia nervosa is the risk of electrolyte imbalance, which can lead to life-threatening complications such as cardiac arrhythmias, seizures, and organ failure. Severe malnutrition can cause low potassium, sodium, and other electrolytes, leading to serious health risks that require immediate intervention and monitoring.

Why Other Options Are Wrong:

A) Fear of gaining weight

While fear of gaining weight is a core symptom of anorexia nervosa, it is a psychological concern and not the immediate physical health concern. The physical risks of malnutrition and electrolyte imbalance take precedence in the initial management.

B) Low academic performance

Low academic performance can result from the cognitive and emotional impact of anorexia nervosa, but it is not the immediate physical health concern. The patient’s medical stability should be addressed first.

D) Body image distortion

Body image distortion is a central feature of anorexia nervosa, but it is primarily a psychological symptom. The physical health concerns, such as electrolyte imbalance, must be addressed first to stabilize the patient before focusing on body image issues.

Correct Answer A. Prepare to administer lorazepam (Ativan) as ordered.

Explanation of Correct Answer:

A. Prepare to administer lorazepam (Ativan) as ordered.

When a client is experiencing alcohol withdrawal symptoms, the priority is to manage withdrawal symptoms safely. Lorazepam (Ativan) is a benzodiazepine commonly used to treat withdrawal symptoms, such as anxiety, agitation, and seizures, that can occur during alcohol withdrawal. Administering the medication as ordered can help prevent severe complications like delirium tremens (DTs), which can be life-threatening.

Why the Other Options Are Incorrect:

B. Support the client's attempt to rebuild damaged interpersonal relationships.

While supporting interpersonal relationships is important in the recovery process, it is not the priority during the acute withdrawal phase. The immediate concern is to stabilize the client and prevent further harm related to alcohol withdrawal.

C. Teach the client about effects of alcohol dependence and the need for rehabilitation.

Education on alcohol dependence and rehabilitation is essential, but it is not the priority during withdrawal. The client’s physical safety and management of withdrawal symptoms must come first before educational interventions.

D. Teach the client alternative strategies for managing anxiety.

While teaching alternative strategies for managing anxiety is helpful for long-term recovery, the priority during alcohol withdrawal is to manage the acute physical symptoms of withdrawal to prevent complications. Anxiety management can be addressed after the client is stable.

Correct Answer C: The client demonstrates coarse hand tremors while reaching for a utensil.

Explanation of Correct Answer:

Coarse hand tremors are an early sign of lithium toxicity. Tremors are one of the first symptoms to appear when lithium levels begin to rise above the therapeutic range. While fine tremors can occur as a normal side effect of lithium, coarse tremors suggest that the levels may be approaching toxicity and should be promptly evaluated.

Why the Other Options Are Incorrect:

A. The client is noted to be experiencing giddiness and sporadic jerking movements while in the day room.

This could be a sign of neurological impairment, but giddiness and sporadic jerking movements are not the most typical early signs of lithium toxicity. Neuromuscular symptoms can occur at high lithium levels but aren't as specific as hand tremors.

B. The client is noted to be drowsy and nod off occasionally during group therapy.

Drowsiness or sedation can occur with lithium, but this is more common as a side effect at therapeutic levels and is not an early sign of toxicity. Lethargy could develop later in the toxicity process but is not a distinguishing feature at the early stage.

D. The client has had a decrease in urinary output over the last 8 hours.

Decreased urinary output is a symptom that could occur with kidney involvement or dehydration, but it is not an early sign of lithium toxicity. In fact, lithium may cause polyuria (increased urination) due to its effect on kidney function, so decreased output is less likely to be an early sign of toxicity.

Correct Answer B: Detachment and flashbacks

Explanation:

Detachment (emotional numbing) and flashbacks are common symptoms of post-traumatic stress disorder (PTSD), especially in survivors of sexual assault. Flashbacks involve re-experiencing the traumatic event, while detachment may involve avoidance of reminders or feelings of disconnection from others. These behaviors are characteristic of the psychological impact of trauma and should be addressed as part of the survivor's recovery.

Why Other Options Are Wrong:

A) Improved sleep

Improved sleep is typically not associated with PTSD. Survivors often experience sleep disturbances, such as insomnia or nightmares, which are symptoms of PTSD rather than improvement in sleep patterns.

C) Increased appetite

Increased appetite may occur in some individuals as a coping mechanism (e.g., emotional eating), but it is not a primary symptom of PTSD. Survivors of trauma may also experience decreased appetite or other signs of emotional distress.

D) Excessive talking

Excessive talking is not a hallmark symptom of PTSD. While some survivors may express themselves verbally, PTSD is more commonly associated with avoidance, detachment, or emotional numbing. Survivors might be more likely to withdraw or avoid discussing the trauma, rather than talking excessively.