ATI RN
Ancc Mental Health Practice Questions Questions
Question 1 of 5
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (
B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (
C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (
D) may impact mental health but does not directly assess immediate risk of suicide.
Question 2 of 5
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia.
Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life.
Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
Question 3 of 5
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
Correct Answer: D
Rationale: The correct answer is D because exploring the impact of the mobility, sight, and hearing changes on the patient allows the nurse to address the patient's holistic needs, including spiritual distress. By understanding the patient's perspective on these changes, the nurse can provide support tailored to the patient's concerns, fostering a sense of connection and understanding.
Choice A is incorrect because focusing solely on childhood religious experiences may not address the current issues the patient is facing.
Choice B is inappropriate as it imposes the nurse's religious beliefs on the patient.
Choice C is also incorrect as it assumes a specific religious approach without considering the patient's individual beliefs and needs.
Question 4 of 5
A nurse is performing an assessment interview of a 14-year-old boy who is being admitted to an adolescent substance abuse unit. His parents are concerned about their son's repeated problems at school that they associate with his drug use. The boy stalks into the office, abruptly sits down, crosses his arms, and says, 'Okay, ask your stupid questions, but don't expect me to cooperate!' Which response by the nurse would be most appropriate?
Correct Answer: D
Rationale: The correct response is D because it acknowledges the boy's emotions, shows empathy, and invites him to share his feelings. By acknowledging his upset feelings, the nurse can build rapport and establish trust, which is crucial in therapeutic communication. This response also opens the door for the boy to express himself and potentially reveal the underlying reasons for his behavior.
Choices A and C are confrontational and judgmental, which can escalate the situation and hinder communication.
Choice B suggests waiting until the boy calms down, which may be dismissive of his emotions and doesn't address the immediate need for connection and understanding.
Question 5 of 5
The statement"Growth involves resolution of critical tasks through the eight stages of the life cycle" is a concept of which therapeutic model?
Correct Answer: A
Rationale: The correct answer is A: Interpersonal. This concept aligns with Erikson's psychosocial theory, which emphasizes the importance of resolving developmental tasks at each stage of life. Interpersonal therapy focuses on relationships and interactions with others, making it the most suitable model for addressing growth through the life cycle.
Choice B (Cognitive-behavioral) focuses on thoughts and behaviors, not developmental stages.
Choice C (Intrapersonal) refers to self-awareness and understanding, not specifically addressing life stages.
Choice D (Psychoanalytic) focuses on unconscious processes and early childhood experiences, not necessarily on resolving tasks through different life stages.