ATI NSG 133 Mental health Exam

Correct Answer B: Carrying an emergency bag

Explanation:

An effective safety plan for a patient experiencing intimate partner violence (IPV) should include practical measures to ensure the patient can quickly leave the situation if needed. One important part of a safety plan is to carry an emergency bag that includes essentials such as identification, medications, money, and important documents. This allows the patient to leave safely and access necessary items without delay in case of an emergency.

Why Other Options Are Wrong:

A) Hiding the abuse from family

Hiding the abuse can increase isolation and mistrust. An effective safety plan encourages the patient to seek support, not to conceal the abuse. It's important to inform trusted individuals and connect the patient with appropriate resources for support.

C) Forgiving the abuser

Forgiving the abuser is not a requirement for safety. The priority is to focus on protecting the patient and ensuring their emotional and physical safety, not on reconciling with the abuser. The patient should be empowered to make their own decisions about forgiveness when they feel ready.

D) Keeping all doors locked at all times

While securing the environment can be a part of safety planning, it is not the primary focus. The key element of a safety plan is to ensure the patient can leave safely if needed. Locking doors may not always be sufficient or possible in every situation, especially if the abuser has control over access points.

Correct Answer B: Risk of violence toward others

Explanation:

Patients with poor anger control are at an increased risk of violence toward others. It is important for the nurse to monitor for signs of escalating anger or aggressive behavior, as these patients may become physically threatening or hurt others. Early recognition of these signs allows the nurse to implement de-escalation techniques and take steps to ensure the safety of the patient and others around them.

Why Other Options Are Wrong:

A) Increased empathy

Poor anger control is typically associated with difficulty in managing emotions, rather than an increase in empathy. Patients with anger issues may have difficulty understanding others' feelings and responding empathetically.

C) Lowered self-esteem

While low self-esteem can contribute to anger issues, the primary concern in patients with poor anger control is the risk of violence toward others. Self-esteem may be an underlying factor but is not the immediate concern in managing anger.

D) Sedation levels

Sedation levels are not typically the primary concern for patients with anger control issues unless they are being medicated for agitation or aggression. The focus is more on monitoring behavioral cues and emotional regulation rather than sedation.

Correct Answer B. I should provide counseling for the family following the suicide of a client.

Explanation of Correct Answer:

B. "I should provide counseling for the family following the suicide of a client."

Tertiary interventions are those provided after a suicide has occurred, focusing on supporting the family, grief counseling, and prevention of future suicides within the family or community. Providing counseling to the family after a client's suicide is a tertiary intervention aimed at helping loved ones cope with the aftermath and prevent further harm.

Why the Other Options Are Incorrect:

A. I should perform screenings to identify clients at risk for suicide.

This is a primary intervention, which focuses on preventing suicide before it happens by identifying individuals at risk and providing early interventions.

C. I should recognize the lethality of the suicide plan.

This statement pertains to secondary interventions, where the nurse assesses the immediacy and risk of a suicide attempt and intervenes to prevent it from occurring.

D. I should provide a safe environment to prevent the client from committing suicide.

This is a secondary intervention, which focuses on preventing the suicide during an active crisis by ensuring the environment is safe and removing potential means of harm.

Correct Answer A: Potassium 2.8 mEq/L

Explanation:

A potassium level of 2.8 mEq/L is critically low and is the most concerning lab value in a patient with bulimia nervosa, especially if they engage in purging behaviors like vomiting or laxative use. Hypokalemia (low potassium) is a life-threatening condition that can lead to cardiac arrhythmias, muscle weakness, and respiratory failure. Patients with bulimia are at high risk for electrolyte imbalances, and a potassium level this low requires immediate medical intervention.

Why Other Options Are Wrong:

B) Hemoglobin 13.5 g/dL

A hemoglobin level of 13.5 g/dL is within the normal range for an adult and does not indicate an immediate concern. Anemia may occur in bulimia patients, but this value is not alarming.

C) Sodium 138 mEq/L

A sodium level of 138 mEq/L is within the normal range (typically 135-145 mEq/L). While electrolyte imbalances can occur in bulimia, this level is not concerning on its own.

D) Calcium 9.2 mg/dL

A calcium level of 9.2 mg/dL is also within the normal range (typically 8.5-10.2 mg/dL). Calcium levels are generally not the most concerning in bulimia unless there is evidence of severe malnutrition or other complications.

Correct Answer:

A) Pain on urination

C) Urinary frequency

D) Urgency

Explanation:

In the presence of a UTI, typical symptoms include:

Pain on urination (A): This is a hallmark symptom of a UTI, often referred to as dysuria. It is caused by inflammation and irritation in the urinary tract.

Urinary frequency (C): The bladder becomes irritated, and the need to urinate occurs more frequently, even when only small amounts of urine are produced.

Urgency (D): A strong and sudden urge to urinate is another common symptom of a UTI. It occurs due to inflammation in the bladder and urethra.

Why Other Options Are Wrong:

B) Excessively dilute urine

UTIs typically cause urine to appear concentrated, not diluted. Dilute urine usually results from excessive fluid intake or conditions like diabetes insipidus, but not from a UTI.

E) Copper-colored urine

Copper-colored urine is not typical for a UTI. It could indicate the presence of blood in the urine (hematuria) or a condition such as hemolysis or liver disease. However, this is not a common symptom of a UTI.

Correct Answer B: Delusions of influence

Explanation:

Delusions of influence refer to the belief that one's behavior, thoughts, or actions are being controlled by an outside force or person. In this case, the nurse is asking about the belief that objects or people have control over the client’s behavior, which fits with delusions of influence.

Why Other Options Are Wrong:

A) Delusions of persecution

Delusions of persecution involve the belief that one is being targeted or harmed by others. While this may involve the belief of being controlled, it is more focused on the idea of being persecuted or harmed, not being influenced by others or objects.

C) Delusions of reference

Delusions of reference involve the belief that neutral events, objects, or behaviors of others have a special meaning directed specifically at the person. This could include believing that something on TV is a direct message to them, but it does not involve the belief that external forces are controlling their actions.

D) Delusions of grandeur

Delusions of grandeur involve the belief that one has exceptional abilities, wealth, fame, or power. This is unrelated to the belief of being controlled by outside forces, as the individual with delusions of grandeur may believe they are special or important, rather than influenced by others.

Correct Answer B: Give the patient space and approach calmly

Explanation:

The priority intervention is to give the patient space and approach him calmly. This is essential in de-escalating the situation. Pacing, clenching fists, and yelling are signs of agitation and frustration, but giving the patient physical space and maintaining a calm, non-threatening demeanor can help prevent further escalation. This approach is part of de-escalation techniques that prioritize patient safety and emotional regulation.

Why Other Options Are Wrong:

A) Call security immediately

Calling security should be reserved for situations where the safety of the patient, staff, or others is at immediate risk. In this case, the patient is agitated but not yet posing a direct threat to others. De-escalation through communication is a better first step.

C) Confront him and explain why his behavior is unacceptable

Confronting the patient in an aggressive or confrontational manner could escalate the situation further. Explaining the behavior is unacceptable might be perceived as accusatory and could increase the patient's agitation.

D) Administer restraints before he escalates further

Restraints should be used only as a last resort and in cases where there is an immediate risk of harm to the patient or others. In this situation, the nurse should first attempt to de-escalate the patient's aggression through calm interaction and giving space before considering restraints.

Correct Answer C. Methadone (Dolophine) and clonidine (Catapres)

Explanation of Correct Answer:

C. Methadone (Dolophine) and clonidine (Catapres)

Methadone is a long-acting opioid agonist used in the treatment of opiate withdrawal. It helps reduce withdrawal symptoms without the euphoric effects of opioids. Clonidine is an alpha-2 adrenergic agonist that helps reduce the sympathetic symptoms of opioid withdrawal, such as agitation, anxiety, and hypertension. This combination is commonly used to manage opiate withdrawal symptoms safely and effectively.

Why the Other Options Are Incorrect:

A. Haloperidol (Haldol) and acamprosate (Campral)

This is incorrect because haloperidol (Haldol) is an antipsychotic used for managing severe agitation or psychosis, not for opioid withdrawal. Acamprosate (Campral) is used in alcohol dependence, not opioid withdrawal.

B. Naloxone (Narcan) and naltrexone (Revia)

This is incorrect because naloxone (Narcan) is an opioid antagonist used for reversing opioid overdose, not for managing withdrawal symptoms. Naltrexone (Revia) is an opioid antagonist used for long-term maintenance in opioid addiction but is not used during acute withdrawal, as it can precipitate withdrawal symptoms.

D. Disulfiram (Antabuse) and lorazepam (Ativan)

This is incorrect because disulfiram (Antabuse) is used for alcohol dependence and is not effective for opioid withdrawal. Lorazepam (Ativan) is a benzodiazepine used for anxiety or agitation but does not specifically treat opioid withdrawal, although it might be used temporarily for anxiety management during withdrawal.

Correct Answer B. Walking with the nurse in the courtyard.

Explanation of Correct Answer:

B. Walking with the nurse in the courtyard.

Clients in the manic phase of bipolar disorder are often hyperactive, impulsive, and may have difficulty focusing on group activities. A one-on-one, low-stimulation activity such as walking with the nurse in the courtyard provides a structured and calm environment. It allows for some physical activity, which can help release excess energy, while also providing an opportunity for the nurse to engage with the client in a safe, supportive manner.

Why the Other Options Are Incorrect:

A. Joining a group discussion about a local election.

While engaging in intellectual activities can be stimulating, it may be too complex for a client in the manic phase, who may have difficulty focusing or staying on topic. The client might become overwhelmed or frustrated with a group discussion, especially if it involves abstract topics like a local election.

C. Participating in a basketball game in the gym.

This is not ideal because clients in the manic phase can have poor impulse control and overexert themselves, which can increase the risk of injury or exacerbate symptoms. Physical activities that are high-energy may be inappropriate for the client in the manic phase as it could lead to unsafe behavior.

D. Watching a video with a group in the day room.

Watching a video in a group setting may not be appropriate for a manic client who might find it hard to sit still and focus. The stimulating environment of a group setting could lead to disruptive behavior or difficulty with attention. Also, a group setting may overwhelm the client, making a solitary activity with fewer distractions more suitable.