ATI Mental Health Practice B 2023

Correct Answer: C

Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development.

Choices A, B, and D are important but not urgent concerns.
Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.

Correct Answer: D

Rationale: The correct answer is D: Determine any physical signs of injury. This should be the first action taken by the nurse in this situation because assessing for physical signs of injury is crucial for ensuring the client's immediate safety and well-being. By assessing for physical injuries, the nurse can prioritize medical treatment if needed and gather important forensic evidence. This initial assessment also helps in determining the urgency of the situation and guides the next steps in providing appropriate care and support.



Choices A, B, and C are incorrect as they are not the priority in this situation. Asking for permission to take photographs, documenting verbatim statements, and providing community sexual assault support contacts are important actions but should come after ensuring the client's immediate physical well-being is addressed. It is essential to focus on the client's physical safety and health first before moving on to other aspects of care and support.

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.

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.

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.