ATI NSG 133 Mental health Exam

 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. The client is a danger to herself or others.

Explanation of Correct Answer:

A. The client is a danger to herself or others.

A client can be kept in the hospital after the 72-hour hold if there is evidence that the client is a danger to herself or others. In this case, the client attacked a neighbor, indicating a potential risk of harm to others. Dangerous behavior is a criterion for extended involuntary commitment in psychiatric settings to ensure the safety of the individual and others.

Why the Other Options Are Incorrect:

B. The client states that she does not like the neighbor.

While this may be concerning behavior, disliking someone does not necessarily indicate that the client poses a danger to others. The client needs to exhibit behavior that is harmful or threatening before extended hospitalization can be considered.

C. The client states that she plans to move out of the state immediately.

The client's intention to move out of state is not a reason for continued hospitalization unless it is accompanied by behavioral concerns or suicidal ideation that pose a risk to the client or others. Simply planning to leave does not meet the criteria for involuntary commitment.

D. The client is unwilling to accept that treatment is needed.

While reluctance to accept treatment can complicate the care plan, it is not in itself a justification for extending hospitalization. The client can be treated involuntarily if they pose a danger to themselves or others, but unwillingness to accept treatment alone is not sufficient to keep them hospitalized beyond the 72-hour hold.

Correct Answer C. Ibuprofen, a nonsteroidal anti-inflammatory agent.

Explanation of Correct Answer:

C. Ibuprofen, a nonsteroidal anti-inflammatory agent.

Ibuprofen is a common NSAID that does not interact with the serotonin system in a way that would increase the risk of serotonin syndrome when taken with venlafaxine. It is generally safe to use NSAIDs like ibuprofen with SSRIs and SNRIs, though caution is required due to the potential for increased risk of gastrointestinal bleeding with concurrent use.

Why the Other Options Are Incorrect:

A. Selegiline, a monoamine oxidase inhibitor (MAOI):

Selegiline, a MAOI, is contraindicated with SSRIs and SNRIs because MAOIs inhibit the breakdown of serotonin and other neurotransmitters, leading to an excessive accumulation of serotonin in the brain. This increases the risk of developing serotonin syndrome, which can be life-threatening.

B. Clomipramine, a tricyclic antidepressant (TCA):

Clomipramine, a TCA, also increases serotonin levels and when combined with venlafaxine, which is an SNRI, can lead to serotonin syndrome. Combining TCAs with other medications that increase serotonin can cause serotonin toxicity.

D. St. John's Wort, a perennial herb:

St. John’s Wort is a herb that has serotonergic effects and is commonly used as a natural remedy for depression. When taken with SSRIs or SNRIs like venlafaxine, it can increase the risk of serotonin syndrome due to its serotonin-enhancing properties. The combination should be avoided to prevent this potentially dangerous reaction.

Correct Answer A: Offer reassurance and validate their experience

Explanation:

The best initial nursing action when a patient discloses abuse is to offer reassurance and validate their experience. It is important for the nurse to create a safe and supportive environment, acknowledging the patient’s feelings without judgment or pressure. Validating the patient’s experience helps build trust and encourages them to open up further about the abuse. This also reassures the patient that they are believed and that they are not at fault.

Why Other Options Are Wrong:

B) Call hospital security

While security may be necessary in certain situations, the first priority should be to address the patient’s emotional and psychological needs. Calling security prematurely could make the patient feel unsafe or misunderstood.

C) Contact child protective services immediately

While contacting authorities, such as child protective services, is crucial in cases involving minors, this is not the first step. The nurse should first ensure the patient feels heard and safe, then follow appropriate protocols for reporting abuse based on the patient's age and the nature of the abuse.

D) Suggest they confront their abuser

Suggesting the patient confront their abuser may not be appropriate, as it can be dangerous and might increase the risk of further harm. The patient should be supported in making their own decisions about confronting the abuser, if and when they are ready, in a safe and controlled environment.

Correct Answer C: Restore nutritional balance and monitor vitals

Explanation:

In the initial phase of treatment for anorexia nervosa, restoring nutritional balance is the priority intervention to address the client’s severe malnutrition. The client’s low weight (78 pounds) indicates that she is at significant physical risk, so the nurse’s immediate focus should be on safely reintroducing nutrition and monitoring vital signs to prevent complications such as electrolyte imbalances, cardiovascular instability, and organ failure. Proper refeeding and close monitoring are critical to ensuring the client’s physical stability and preparing them for further psychological interventions.

Why Other Options Are Wrong:

A) Encourage family therapy

Family therapy is an important part of treatment for anorexia nervosa, as it helps address family dynamics and support the patient's recovery. However, it is not the initial priority. Physical stabilization through nutritional restoration is the first step.

B) Begin daily psychotherapy

Psychotherapy is essential in addressing the psychological aspects of anorexia nervosa, including body image distortion and fear of gaining weight. However, in the initial phase of treatment, the client’s physical health and nutritional status must be stabilized before effective psychotherapy can occur.

D) Focus on improving self-esteem

While improving self-esteem is an important long-term goal in treating anorexia nervosa, the immediate focus should be on the client’s physical health and nutritional needs. Self-esteem work can be addressed once the client’s physical state is more stable.

Correct Answer B: Irregular heart rate

Explanation:

A hallmark sign of anorexia nervosa is an irregular heart rate, which can occur due to severe malnutrition and electrolyte imbalances resulting from extreme weight loss and starvation. The heart can become weakened and arrhythmic due to these imbalances, posing serious health risks. This is often seen in patients with severe anorexia nervosa and is a significant concern during treatment.

Why Other Options Are Wrong:

A) Elevated blood pressure

Elevated blood pressure is not typically associated with anorexia nervosa. In fact, patients with anorexia often experience low blood pressure due to malnutrition and dehydration.

C) Rapid weight gain

Rapid weight gain is not characteristic of anorexia nervosa, as this disorder is defined by severe weight loss and restriction of food intake. Rapid weight gain is more commonly seen in disorders like bulimia nervosa or other eating disorders with binge eating behaviors.

D) Low self-esteem

While low self-esteem is common in patients with anorexia nervosa and can contribute to the development and persistence of the disorder, it is not the hallmark sign of anorexia. The primary features of anorexia nervosa are extreme food restriction, severe weight loss, and physical complications like irregular heart rate.

Correct Answer C: Stay with the client.

Explanation:

The priority action during a panic attack is to stay with the client to provide reassurance and comfort. Clients with panic attacks often feel overwhelmed and may experience intense fear and physical symptoms such as rapid heartbeat, difficulty breathing, and dizziness. Remaining with the client provides a sense of security and can help reduce anxiety. Additionally, maintaining a calm and supportive presence can aid in de-escalating the situation.

Why Other Options Are Wrong:

A) Escort the client to the common area.

While it may be helpful to guide the client to a more calming environment, the priority is staying with the client to provide immediate reassurance and prevent escalation. Moving the client during a panic attack might increase anxiety.

B) Contact security for possible restraints.

Restraints should be used as a last resort in situations of extreme danger to the client or others. For a panic attack, using restraints is not necessary or appropriate. The focus should be on calming and reassuring the client.

D) Stay away from the client.

Remaining distant from the client could increase feelings of abandonment and isolation, which may exacerbate the panic attack. Staying with the client is the most supportive and therapeutic approach.

Correct Answers:

B. The client is seeking sympathy and pity from healthcare providers by feigning illness or injury.

C. The client is seeking attention and validation through inducing injury or illness.

Explanation of Correct Answers:

B. The client is seeking sympathy and pity from healthcare providers by feigning illness or injury:

One of the core features of fictitious disorder (previously known as Munchausen syndrome) is the client intentionally feigning illness or injury in order to gain sympathy or attention from healthcare providers. This behavior is not driven by external rewards, such as financial gain.

C. The client is seeking attention and validation through inducing injury or illness:

This is another hallmark of fictitious disorder. The client may go to great lengths to induce symptoms or self-harm to receive attention and validation from others. This could involve exaggerating or intentionally causing injury or illness.

Why the Other Options Are Incorrect:

A. The client is experiencing physical symptoms related to an underlying medical condition:

This is not consistent with fictitious disorder. Clients with fictitious disorder fabricate or induce symptoms rather than presenting with genuine physical symptoms related to an underlying medical condition. The focus is on deceptive behavior rather than the presence of true medical conditions.

D. The client is seeking financial gain through feigning illness or injury:

This is characteristic of malingering, not fictitious disorder. In malingering, individuals deliberately fabricate or exaggerate symptoms for tangible external rewards, such as financial gain. Fictitious disorder, on the other hand, is driven by psychological needs, such as attention and sympathy, rather than material gain.

E. The client's symptoms are the result of a misdiagnosis or medical error:

This hypothesis would not be applicable to fictitious disorder. The client is intentionally creating or exaggerating symptoms, not experiencing symptoms due to a misdiagnosis or medical error.

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.