(NGN) ATI Mental Health Final Proctored Exam Correct Solutions/A+ Grade

1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should the nurse plan to take? a) Restrict participation in group therapy sessions b) Establish consequences for self-mutilation c)Maintain close observation d) Provide an unstructured environment - c) Maintain close observation Clients who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury 2. A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What action should the nurse take? - Administer the medication at bedtime. 3. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." What response should the nurse make? - "That must be very frightening." The nurse should respond to the client's delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship. 4. A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect? - Confusion. The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are expected findings of this disorder. 5. A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which manifestations is a common adverse effect of this medication? - Dizziness. The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects is determined. 6. A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. What finding should the nurse question the provider's prescription? - Hypotension. The nurse should question the provider's prescription for a benzodiazepine for a client who has hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac arrest. 7. A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the priority for the nurse to report to the provider? - Elevated blood pressure. The nurse should identify that the greatest risk to the client is an elevated blood pressure, which increases the risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction priority-setting framework when assessing this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting frame-work, or nursing knowledge to identify which risk poses the greatest risk.