ATI RN Mental Health

The Correct Answer is:

D. Agoraphobia

Explanation:

Agoraphobia is characterized by the fear of being in situations where escape might be difficult or help unavailable, leading to avoidance of places such as open spaces, public places, or being outdoors alone. The client’s fear of leaving her home and being outdoors alone fits the definition of agoraphobia.

Why the other options are incorrect:

A. Mysophobia

Mysophobia is the fear of germs or dirt. It does not match the client's fear of being outdoors alone.

B. Xenophobia

Xenophobia refers to the fear of strangers or foreigners. This does not align with the fear described in the scenario, which is about leaving the home and being outdoors alone.

C. Acrophobia

Acrophobia is the fear of heights. While it involves a specific fear, it does not describe the generalized fear of being outside or away from home, as seen in agoraphobia.

The Correct Answer is:

Increase your fluid and fiber intake to prevent constipation.

Explanation:

Risperidone, an atypical antipsychotic, can cause constipation due to its anticholinergic effects, which slow gastrointestinal motility. To prevent constipation, the nurse should encourage the client to increase their fluid and fiber intake. Regular physical activity can also help, but maintaining hydration and a fiber-rich diet are key to preventing constipation when taking risperidone.

Why the other options are incorrect:

Have your blood pressure checked frequently for hypertension.

Risperidone is more likely to cause orthostatic hypotension (low blood pressure upon standing) rather than hypertension. Therefore, frequent blood pressure monitoring for hypertension is not a primary concern, but monitoring for orthostatic hypotension is important.

Expect to have your blood checked weekly for serum electrolyte imbalances.

Routine weekly blood tests for electrolyte imbalances are not required for clients on risperidone. However, electrolyte imbalances, especially related to sodium levels, are a concern in certain medications (like diuretics), but not commonly with risperidone.

Increase caloric intake to prevent weight loss.

Risperidone is more commonly associated with weight gain, rather than weight loss, due to its metabolic effects. Therefore, there is no need to specifically increase caloric intake to prevent weight loss. Instead, clients should be monitored for weight gain and metabolic changes.

The Correct Answer is:

C. A client who has schizophrenia and is taking antipsychotic medication.

Explanation:

Extrapyramidal symptoms (EPS) are a group of movement disorders that are commonly caused by antipsychotic medications, particularly the first-generation (typical) antipsychotics. EPS include symptoms such as tremors, rigidity, bradykinesia, tardive dyskinesia, and akathisia. Since the client with schizophrenia is taking antipsychotic medication, they are at risk for developing these symptoms.

Why the other options are incorrect:

A. An adult client who has type 2 diabetes mellitus and is taking insulin.

Insulin therapy does not cause extrapyramidal symptoms. The primary concern in this case is managing blood sugar levels and preventing complications related to diabetes.

B. A client who is in the third trimester of pregnancy and taking iron supplements.

Iron supplements are typically used to treat anemia during pregnancy, and they do not cause extrapyramidal symptoms. The focus during pregnancy is on ensuring adequate iron intake and monitoring for any pregnancy-related complications.

D. An older adult client who has pancreatitis and is taking enzymes.

Enzyme replacement therapy for pancreatitis does not cause extrapyramidal symptoms. The primary goal is to manage pancreatic enzyme deficiency and alleviate digestive symptoms.

The Correct Answer is:

D. Diazepam

Explanation:

Diazepam, a benzodiazepine, is commonly used to manage acute alcohol withdrawal symptoms. It helps reduce anxiety, agitation, and the risk of seizures associated with alcohol withdrawal. Benzodiazepines like diazepam are considered first-line treatment during the acute withdrawal phase because they can help stabilize the client and prevent serious complications such as delirium tremens and seizures.

Why the other options are incorrect:

A. Naltrexone

Naltrexone is used to help reduce cravings and prevent relapse in people who are in recovery from alcohol use disorder, but it is not used during the acute withdrawal phase. It works by blocking the effects of alcohol and reducing the desire to drink.

B. Acamprosate

Acamprosate is used to help maintain alcohol abstinence after the detoxification and withdrawal phase. It works by reducing the physical and emotional distress that can occur during abstinence but is not used during acute withdrawal.

C. Disulfiram

Disulfiram is used as part of alcohol use disorder treatment to create an unpleasant reaction when alcohol is consumed. It is not used during the withdrawal phase because it is intended for long-term maintenance, not for managing acute withdrawal symptoms.

The Correct Answer is:

D. SSRIs increase serotonin levels by preventing its reuptake into neurons.

Explanation:

Selective serotonin reuptake inhibitors (SSRIs) work by blocking the reuptake (reabsorption) of serotonin into the presynaptic neuron. This increases the availability of serotonin in the synaptic cleft, enhancing mood and helping to alleviate symptoms of depression and anxiety. SSRIs do not directly affect serotonin production but instead increase its levels in the brain by inhibiting its reuptake.

Why the other options are incorrect:

A. SSRIs increase norepinephrine levels to elevate mood.

This statement is incorrect because SSRIs primarily target serotonin, not norepinephrine. Medications that increase norepinephrine levels, such as norepinephrine reuptake inhibitors (NDRIs), have a different mechanism of action.

B. SSRIs inhibit serotonin production in the brain.

SSRIs do not inhibit serotonin production. Instead, they increase serotonin levels in the synaptic cleft by preventing its reuptake into neurons.

C. SSRIs decrease dopamine levels to improve mood.

SSRIs primarily affect serotonin levels, not dopamine. While dopamine plays a role in mood regulation, SSRIs do not directly decrease dopamine levels.

The Correct Answer is:

D. Inform the client photographs of injuries are required for a police report.

Explanation:

In cases of sexual assault, it is important to preserve evidence, and photographs of injuries may be needed for legal purposes. The nurse should inform the client that photographs may be taken, but should also ensure that the client’s rights and dignity are maintained. The decision to have photographs taken should be explained to the client, and their consent should be obtained before proceeding. However, the nurse should never pressure the client into participating if they are not comfortable with it.

Why the other options are incorrect:

A. Ask the client to describe the situation.

The nurse should not immediately ask the client to describe the assault unless the client is ready to share. It is essential to avoid putting the client in a position where they feel forced to relive the trauma. The nurse should provide a safe space for the client to speak when they are ready, and offer support through appropriate channels, such as a counselor or social worker.

B. Give the client a bed bath prior to physical examination.

The client should not be bathed before a physical examination to preserve evidence. Bathing could remove potential forensic evidence that may be needed for a police report. The nurse should ensure that the client is not washed, and care should be taken to preserve any physical evidence, including clothing or bodily fluids.

C. Discuss self-defense techniques with the client.

While self-defense may be important to discuss at a later time for prevention, it is not an immediate priority during the acute care phase. The focus should be on the client’s immediate safety, physical and emotional well-being, and providing the necessary care for the assault.

The Correct Answer is:

B. Conduct a thorough assessment to evaluate John's safety and risk of harm to himself or others.

Explanation:

The priority nursing action is to assess John’s safety, including the risk of self-harm or harm to others, given his current symptoms of extreme mood swings, risky behaviors during manic episodes, and feelings of hopelessness during depressive episodes. This assessment helps determine the urgency of intervention and ensures that immediate safety concerns, such as suicidal ideation or impulsive actions, are addressed.

Why the other options are incorrect:

A. Administer a mood stabilizer immediately.

While administering a mood stabilizer is an important part of managing bipolar disorder, the priority action is to first assess the client’s safety. Immediate intervention with medication can follow after safety concerns are addressed.

C. Schedule John for regular therapy sessions to manage his mood swings.

Therapy sessions are important for long-term management of bipolar disorder, but the immediate priority is ensuring John’s safety before focusing on therapy scheduling.

D. Educate John and his wife about the signs and symptoms of Bipolar Spectrum Disorder.

Education is an essential component of treatment, but it is not the immediate priority. The nurse must first ensure the client’s safety before providing education.

The Correct Answer is:

C. A client who has a WBC of 2,900 cells/mm3

Explanation:

Clozapine is an atypical antipsychotic that can cause a significant side effect known as agranulocytosis, a severe reduction in white blood cell (WBC) count, which can increase the risk of infection. A WBC of 2,900 cells/mm³ is below the normal range (typically 4,000 to 11,000 cells/mm³) and indicates that the client may be at risk for infection. The nurse should withhold clozapine and notify the provider immediately to assess the client’s condition and potentially discontinue clozapine therapy.

Why the other options are incorrect:

A. A client who has a serum potassium of 3.3 mEq/L

Although a potassium level of 3.3 mEq/L is slightly low (normal range is 3.5 to 5.0 mEq/L), it is not an immediate contraindication for clozapine therapy. However, this should be monitored, and interventions to correct potassium levels may be necessary.

B. A client who has a hematocrit of 55%

A hematocrit of 55% is high, which could indicate dehydration or other conditions, but it is not directly related to clozapine use. This finding does not require immediate discontinuation of clozapine, though further investigation is needed.

D. A client who has a BUN of 22 mg/dL

A BUN (blood urea nitrogen) level of 22 mg/dL is slightly elevated (normal range is 7-20 mg/dL), but it is not directly indicative of a problem that requires immediate discontinuation of clozapine. This may require monitoring for kidney function but is not a critical concern for clozapine use.

The Correct Answer is:

C. Increased appetite and weight gain

Explanation:

A common side effect of many antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), is increased appetite, which can lead to weight gain. This side effect is important to mention because it can impact the patient's overall health and medication adherence.

Why the other options are incorrect:

A. Improved concentration

While antidepressants may help improve mood and cognitive function over time, they are not typically associated with immediate improvements in concentration. In fact, some antidepressants may cause cognitive side effects like drowsiness or difficulty concentrating in the early stages of treatment.

B. High blood pressure

While certain antidepressants, such as monoamine oxidase inhibitors (MAOIs) and some stimulants, can affect blood pressure, high blood pressure is not a common side effect of most antidepressants.

D. Hair loss

Hair loss is not a common side effect of antidepressants. However, in some cases, it can occur with certain medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs), but it is less frequent.