ATI Mental Health Detailed Answer Key, 2024 (UPDATED) with 100%Verified Complete Solutions.
A client with bipolar disorder who is prescribed lithium is
... [Show More] receiving teaching regarding this medication and is
preparing to be discharged from the mental health facility. The nurse determines that the teaching was
effective when the client states that which of the following is a manifestation of lithium toxicity?
Rationale: Lithium is a medication used to treat bipolar disorder. Early manifestations of toxicity
include diarrhea, lethargy, impaired coordination, muscle weakness, nausea or
vomiting, slurred speech, and trembling. If the client experiences vomiting and
diarrhea, the client should omit the next dose of lithium and call the provider.
A. Vomiting and diarrhea
Rationale: Increased flatulence is a common side effect of lithium, but it is not a sign of lithium
toxicity.
B. Increased flatulence
Rationale: Loss of appetite is a common side effect of lithium, especially during the body's
adjustment to the medication, but it is not a sign of lithium toxicity.
C. Loss of appetite
Rationale: Increased urination is a common side effect, but it is not a sign of lithium toxicity.
Clients who experience this side effect should be instructed to increase fluid intake
to prevent dehydration.
D. Increased urination
1.
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Detailed Answer Key
Homework 23 - Mental Health
A nurse is caring for a client hospitalized for treatment of severe depression. Which of the following strategies
should the nurse plan to contribute to the client's plan of care?
Rationale: This is not an appropriate nursing approach to include in this client's plan of care.
Making choices is difficult for a client who has depression.
A. Giving the client choices of activities
Rationale: This option uses the therapeutic communication tool of being silent. Depression also
involves diminished self-esteem, and spending time with the client conveys that he
is worth the nurse's time and attention.
B. Spending time with the client
Rationale: An intellectual game that requires making choices and decisions, such as chess,
would not be a good activity for a depressed client.
C. Playing a game of chess with the client
Rationale: This is not an appropriate nursing approach to include in this client's plan of care.
Decision making is difficult for a depressed client.
D. Encouraging decision making
2.
The parents of a 4-year-old child who has a serious chronic illness tell the nurse that they have taken their son’
s name off the list for little league baseball next season. Which of the following is an appropriate nursing
response to the parents?
Rationale: This response demonstrates the therapeutic communication technique of sharing
empathy. It is neutral and nonjudgmental and invites further communication and
sharing.
A. “It must be frustrating for you to have to cancel an activity your son enjoyed.”
Rationale: This response is stereotypical and fails to convey empathy and understanding.
B. “Baseball can be a dangerous sport for children.”
Rationale: With this response, the nurse gives the parents false reassurance, which is a
nontherapeutic communication technique.
C. “You never know. He could be ready for baseball by the spring.”
Rationale: This response illustrates the nontherapeutic communication technique of offering
sympathy. Although it shows compassion, it also demonstrates pity or subjectivity
rather than the objectivity that can truly help solve a problem or offer support.
D. “I’m so sorry that you felt you had to do that.”
3.
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Detailed Answer Key
Homework 23 - Mental Health
A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear
that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is
appropriate?
Rationale: This statement acknowledges the reality of the voices and encourages the client to
argue with the voices, both of which are nontherapeutic approaches for
communication with a client who is experiencing a hallucination.
A. “You need to tell the voices to leave you alone.”
Rationale: Negating the client’s perception of the hallucination is a nontherapeutic approach for
communication with a client who is experiencing a hallucination.
B. “There are no voices.”
Rationale: This statement recognizes the risk involved with a command hallucination and asks
the client directly about the hallucination. This is a therapeutic approach to
communicating with a client who is experiencing a hallucination.
C. “What are the voices telling you to do?”
Rationale: Asking a “why” question is nontherapeutic and increases the defensiveness of a
client experiencing a hallucination.
D. “Why do you think you are hearing the voices?”
4.
A nurse is caring for a client who has obsessive-compulsive disorder. The client has a full set of dentures
because he eroded all his tooth enamel with his brushing rituals. He also brushes his tongue several times a
day and has developed several ulcerations. In planning the client's care, encouraging which of the following
should be the initial priority?
Rationale: Restoring physiological integrity is the highest initial priority for this client. This will
be done while working on the long-term goal of decreasing the mouth care rituals.
A. Establishing appropriate oral hygiene routines
Rationale: This is not the highest priority.
B. Verbalizing the causes of his ritualistic behavior
Rationale: This is not the highest priority.
C. Ensuring that the client relies on the nurse when he is feeling anxious
Rationale: This is not the highest priority.
D. Minimizing the client's excessive mouth care rituals
Rationale: This is not the highest priority. [Show Less]