ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
Correct Answer: A, B, D
Rationale: The correct choices for the nurse to include in the MSE for a client with dementia are A, B, and D. Grooming is important to assess the client's self-care ability, which can be impacted by dementia. Long-term memory is essential in evaluating cognitive decline typically seen in dementia. Affect assessment helps determine emotional responses and can indicate changes in mood associated with dementia. Support systems (choice
C) are not typically part of the MSE but are relevant for treatment planning. Presence of pain (choice E) is important but not a traditional component of a mental status examination.
Question 2 of 5
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (
B), identifying coping skills (
C), and support systems (
D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
Question 3 of 5
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "I'll just sit here with you for a few minutes then." This response demonstrates empathy and support without imposing solutions or pressuring the client to talk. It acknowledges the client's feelings and offers companionship, which can provide comfort and reassurance.
Choice A may pressure the client to talk, which may not be what the client needs at the moment.
Choice C shifts the focus to the nurse's own experiences, which may not be helpful for the client.
Choice D may come across as confrontational or dismissive of the client's emotions.
Therefore, choice B is the most appropriate response in this situation.
Question 4 of 5
A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response acknowledges the partner's desire to bring food from home while also emphasizing the importance of adhering to the client's dietary plan for recovery. By suggesting a compromise to incorporate the favorite food within the diet plan, the nurse is promoting collaboration and patient-centered care. It shows understanding and empathy towards the partner's concerns while prioritizing the client's health and recovery.
Choice A is incorrect as it may come off as judgmental and dismissive.
Choice B is not the most appropriate response as it doesn't address the partner's request directly.
Choice C is incorrect as it may sound like a blanket statement and could potentially create tension between the nurse and the partner.
Question 5 of 5
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (
A) is important but not the immediate priority. Changing policies (
B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (
D) is important for support but does not directly address staff intervention.