ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I'm being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: "We are here to help you and give you the care that you need right now." This response acknowledges the client's feelings, reassures them of support, and validates their experience without dismissing their concerns. It promotes a therapeutic relationship and trust-building.
Choice A is incorrect as it does not address the client's immediate distress.
Choice B is also incorrect as it may come across as invalidating the client's feelings.
Choice D is incorrect as it suggests a quick fix without addressing the client's underlying concerns.
Question 2 of 5
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Hand tremors. During acute alcohol withdrawal, the central nervous system is hyperexcitable due to the sudden absence of alcohol. This can lead to symptoms such as hand tremors, anxiety, agitation, and even seizures. Stuporous level of consciousness (choice
B) is not expected in alcohol withdrawal, as clients typically exhibit hyperactivity. Bradycardia (choice
C) and hypotension (choice
D) are unlikely findings, as alcohol withdrawal commonly causes increased heart rate and blood pressure due to sympathetic nervous system activation.
Question 3 of 5
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
Correct Answer: C
Rationale: The correct answer is C because the partner losing 20 lb in the past 2 months indicates caregiver role strain. Significant weight loss can be a sign of stress, neglecting self-care, and being overwhelmed by caregiving responsibilities. This observation suggests that the partner may not be prioritizing their own well-being while caring for the client with Alzheimer's disease.
Choice A is incorrect because placing locks at the top of doors is a safety measure commonly taken to prevent the client with Alzheimer's disease from wandering outside unsupervised.
Choice B is incorrect as hiring a house cleaner can be a practical solution to manage household tasks and does not necessarily indicate caregiver role strain.
Choice D is incorrect because redirecting the client when frustrated is a positive caregiving technique to manage challenging behaviors.
Question 4 of 5
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale: Option B, "I know which of my hallucinations trigger a relapse," indicates the client's understanding of identifying triggers for relapse. This awareness is crucial in preventing relapse by avoiding or managing triggers effectively. Understanding personal triggers helps the client take proactive steps to maintain stability.
Incorrect
Choices:
A: "I can remember when my hallucinations first began." This statement does not demonstrate a proactive plan for relapse prevention.
C: "I record the number of hallucinations I have each day." Monitoring hallucinations is important but does not necessarily indicate understanding of relapse prevention.
D: "I will read as much information as I can about schizophrenia." While education is vital, it does not directly address relapse prevention strategies.
Question 5 of 5
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
Correct Answer: C
Rationale: The correct answer is C because disorganized speech is a key symptom of acute mania in bipolar disorder. Disorganized speech is characterized by incoherent, rapid, and tangential responses, reflecting the racing thoughts and pressured speech commonly seen in manic episodes. This symptom is indicative of a manic state, which is a defining feature of bipolar disorder.
Choices A, B, and D are incorrect because they do not directly relate to the diagnostic criteria for acute mania. Weight gain, clothing color choice, and auditory hallucinations are not specific to mania and could be present in other mental health conditions.