ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me." The nurse responds, "I understand, but it is time for group therapy, and we expect everyone to attend. Let's walk over together.” For which of the following reasons is the nurse's response considered therapeutic?
Correct Answer: A
Rationale: The correct answer is A because the nurse's response clearly articulates what is expected of the client, which helps maintain structure and promote accountability. By stating the expectation for the client to attend group therapy, the nurse is establishing boundaries and reinforcing the therapeutic environment. This approach helps the client understand the importance of participating in treatment activities.
Choice B is incorrect because empathy towards the delusion may validate the client's false beliefs, which is not therapeutic in this context.
Choice C is incorrect as the response is not primarily aimed at setting limits on manipulative behavior but rather at promoting participation in therapy.
Choice D is incorrect as the response does not involve reflection but rather straightforward communication of expectations.
Question 2 of 5
A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?
Correct Answer: A
Rationale: The correct answer is A: Offer to make arrangements for the Sacrament of the Sick. This is appropriate because the client is a practicing Roman Catholic, and the Sacrament of the Sick is a sacrament in the Catholic faith administered to the sick or dying. Offering to arrange for this sacrament shows respect for the client's religious beliefs and provides spiritual comfort.
Choice B is incorrect because staying with the client's body after death is not necessarily a religious practice and may not align with the client's beliefs.
Choice C is incorrect as it assumes the client's faith requires a specific individual to bathe the body, which may not be the case for all Roman Catholics.
Choice D is incorrect as it is not relevant to the client's religious needs and may hinder communication during this sensitive time.
Question 3 of 5
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
Correct Answer: A
Rationale: The correct answer is A: Protecting the client from injury. This is the highest priority because ensuring the client's physical safety takes precedence in a crisis situation. If the client is at risk of harming themselves or others, immediate action must be taken to prevent injury. Determining the cause of anxiety, ensuring the client feels safe, and identifying coping skills are important but secondary priorities once the client's safety is assured. In a crisis situation, physical safety is paramount before addressing underlying causes or providing emotional support.
Question 4 of 5
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (
A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (
B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (
D) is a good intervention but should come after providing immediate support and understanding the client's needs.
Question 5 of 5
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.