ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
Correct Answer: C
Rationale:
Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (
A) recommending long-term care, (
B) suggesting counseling, and (
D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
Question 2 of 5
A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
Correct Answer: C
Rationale:
Correct
Answer: C
Rationale: The nurse should respond with "What is it about the adverse effects that concern you?" This response shows empathy, encourages open communication, and allows the nurse to address the client's specific fears or concerns. It also promotes a patient-centered approach to care, enhancing trust and rapport between the nurse and the client. This response demonstrates active listening and provides an opportunity for individualized education and support.
Incorrect Answers:
A: This response defers the responsibility to the provider and does not address the client's concerns directly.
B: This response does not address the client's specific concerns and may not provide the necessary support.
D: This response dismisses the client's concerns and does not address the root of her worries, potentially increasing anxiety.
E, F, G: No information provided.
Question 3 of 5
A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
Correct Answer: C
Rationale: Rationale for Correct Answer C: The nurse should acknowledge the son's feelings of being torn between staying with his parent and going home to his children. This response demonstrates empathy and understanding of the son's emotional struggle, validating his concerns. By acknowledging his conflicting emotions, the nurse can help the son process his feelings and make a decision that aligns with his needs and responsibilities.
Summary of Incorrect
Choices:
A: This response does not address the son's emotional conflict and does not offer support or validation.
B: This response focuses on the nurse's care for the parent, disregarding the son's emotional needs.
D: This response dismisses the son's concerns and suggests leaving without considering his emotional state or responsibilities.
Question 4 of 5
A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
Correct Answer: A
Rationale:
Correct
Answer: A. Seclusion is contraindicated for an adult client following a suicide attempt. This client may already be in a vulnerable state and seclusion could exacerbate feelings of isolation and hopelessness, potentially leading to further harm. It is important to maintain close observation and provide supportive interventions.
Incorrect
Choices:
B: Seclusion may be considered for a school-age client who attempts to bite staff to ensure the safety of both the client and staff.
C: Seclusion may be necessary for an adolescent client who poses a risk to others by throwing objects to prevent harm to self and others.
D: Seclusion may be used for an older adult client who is manic and overstimulated to provide a calm and safe environment for de-escalation.
Question 5 of 5
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (
A) is important to evaluate cognitive function. Recall ability (
C) is crucial as memory impairment is a common feature of dementia. Long-term memory (
D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (
B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.