ATI RN
ATI RN Mental Health 2019 NGN Questions
Question 1 of 5
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Sore throat. This is the priority finding to report because it could indicate a potential serious side effect of clozapine called agranulocytosis, which is characterized by a low white blood cell count and can lead to severe infections. Agranulocytosis is a life-threatening condition that requires immediate medical attention. Reporting this finding promptly allows for early intervention to prevent complications.
Other choices are less urgent: A: Random blood glucose 130 mg/dL is slightly elevated but not immediately concerning. B: Heart rate 104/min may be within normal range depending on the individual. C: Nausea is a common side effect of clozapine but not as critical as a sore throat.
Question 2 of 5
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Obtain the provider's prescription within 60 min. This is crucial as placing a client in seclusion is considered a restrictive intervention that requires a provider's order for legality and ethical reasons. Obtaining the prescription promptly ensures the client receives appropriate care and legal compliance.
Incorrect choices:
A: Document the client's behavior every 15 min - While documentation is important, obtaining the provider's order takes priority.
C: Offer the client food and fluids every 2 hr - Not the immediate concern when a client is physically aggressive and in seclusion.
D: Monitor the client's vital signs every 4 hr - Monitoring vital signs is important, but obtaining the provider's order is more urgent in this scenario.
Question 3 of 5
A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Provide consistent boundaries for the client. This is essential in caring for clients with borderline personality disorder as it helps establish clear expectations and limits, which can reduce feelings of confusion and anxiety. Consistent boundaries also help the client understand appropriate behavior and promote a sense of safety and security.
Choice A is incorrect because while maintaining consistency in assigning health care staff may be beneficial in some cases, it is not as crucial as providing consistent boundaries for clients with borderline personality disorder.
Choice B is incorrect because while demonstrating a sympathetic attitude is important, it is not as effective as setting clear boundaries for clients with this disorder.
Choice D is incorrect because encouraging the use of countertransference (therapist's emotional response to a client) is not recommended and can be detrimental to the therapeutic relationship.
In summary, providing consistent boundaries is the most appropriate action when caring for a client with borderline personality disorder as it promotes a structured and therapeutic environment.
Question 4 of 5
A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?
Correct Answer: D
Rationale: The correct answer is D: Are you having thoughts about harming yourself? This question is the priority because it assesses the client's risk of self-harm or suicide, which is crucial in a situational crisis. It allows the nurse to identify potential danger and provide immediate intervention if needed.
Choices A, B, and C focus on general coping mechanisms and understanding the client's current situation, which are important but not as urgent as ensuring the client's safety.
Question 5 of 5
A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?
Correct Answer: A
Rationale: The correct answer is A - a client who has moderate-stage Alzheimer's disease should be placed closest to the nurse's station. This is because clients with Alzheimer's may have memory loss, confusion, and wandering tendencies, requiring close monitoring and quick access to assistance. Placing them near the nurse's station ensures prompt intervention in case of emergencies or wandering episodes. Clients with other conditions like schizotypal personality disorder, alcohol use disorder, or dependent personality disorder may not require immediate proximity to the nurse's station based on their specific needs, making them less urgent choices for room assignment.