ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C - Ask the client direct questions about the hallucination. This approach helps the nurse understand the client's experience without validating or denying the hallucination. It shows empathy and promotes trust.
Choice A would validate the hallucination, worsening the client's condition.
Choice B could escalate the situation by encouraging confrontation with the voices.
Choice D may cause the client to feel dismissed or judged. Asking direct questions (
C) allows the nurse to gather information, assess the client's safety, and provide appropriate care.
Question 2 of 5
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time, and they are trying to poison my food." Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without denying or confirming the delusions. It shows empathy and validates the client's experience without reinforcing the delusions. Option A is incorrect as it denies the client's beliefs, which can lead to distrust. Option C may encourage the client to provide more details about the delusions. Option D may inadvertently validate the delusions by asking for specific details.
Question 3 of 5
A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting?
Correct Answer: B
Rationale: The correct answer is B: Grandiosity. The client's belief that they can do anything, like flying and becoming a U.S. Senator, reflects grandiosity, a symptom of bipolar disorder's manic phase. This is characterized by an inflated sense of self-importance and abilities. Flight of ideas (
A) is a rapid shifting of thoughts, not seen in this scenario. Impaired reality testing (
C) involves difficulty distinguishing between reality and fantasy; this client is not questioning reality. Depersonalization (
D) is feeling detached from oneself, not demonstrated here.
Question 4 of 5
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Provide a consistent daily routine. Individuals with Alzheimer's disease benefit from a structured routine as it helps reduce confusion and anxiety. Consistency in daily activities can enhance familiarity and comfort for the client, promoting a sense of security and predictability. This routine can also aid in maintaining the client's cognitive function and overall well-being.
Incorrect choices:
A: Post a written schedule of daily activities - While this may be helpful, a consistent routine is more effective in providing stability for individuals with Alzheimer's.
B: Use an overhead loudspeaker to announce events - Loud noises and sudden announcements can be overwhelming for individuals with Alzheimer's, causing distress.
D: Allow the client to choose free-time activities - While promoting autonomy is important, too many choices can lead to confusion and difficulty in decision-making for individuals with Alzheimer's.
Question 5 of 5
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Psychomotor agitation. In major depressive disorder, psychomotor agitation is a common symptom characterized by restlessness, pacing, fidgeting, or hand-wringing. This is due to the increased inner tension and anxiety experienced by the individual. Dismissal of past failures (
A) is not a typical finding in major depressive disorder, as individuals often dwell on negative thoughts. An increase in energy (
C) is unlikely, as fatigue and low energy levels are more common in depression. The other choices are not provided, but it's important to remember that psychomotor agitation can be a key indicator in identifying major depressive disorder.