ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
Question 2 of 5
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale: Asking the client to agree to talk to a nurse whenever she feels the urge to exercise is the most appropriate action. This approach promotes open communication and allows for timely intervention to address the client's excessive exercise behavior. It also demonstrates empathy and support, which are crucial in managing anorexia nervosa. By creating a safe space for the client to express her feelings, the nurse can help prevent further harm caused by overexercising.
Summary of other choices:
A: Praising the client for looking at herself in a mirror may reinforce distorted body image perceptions and unhealthy behaviors.
C: Reprimanding the client could lead to feelings of guilt and shame, exacerbating the client's condition.
D: Restricting the client from being weighed may not address the underlying issue of overexercising and can contribute to feelings of lack of control.
Question 3 of 5
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice
A), diaphoresis (choice
B), and tremors (choice
C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations.
Therefore, addressing visual hallucinations takes priority over these symptoms.
Question 4 of 5
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
Correct Answer: C
Rationale: The correct answer is C: Major depressive disorder. Clients with major depressive disorder are at the highest risk for suicide due to the severity of their symptoms, including feelings of hopelessness, worthlessness, and suicidal ideation. This diagnosis is associated with a higher rate of completed suicides compared to other depressive disorders. Clients with premenstrual dysphoric disorder (
A) experience mood changes related to their menstrual cycle but do not typically have an increased risk of suicide. Seasonal affective disorder (
B) is characterized by seasonal changes in mood and energy levels but is not typically associated with a high risk of suicide. Persistent depressive disorder (
D) involves chronic depressive symptoms but does not necessarily indicate an increased risk of suicide.
Question 5 of 5
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.