ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Question 1 of 5
A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Implement measures to prevent intentional self-inflicted injury. This is the priority because individuals with borderline personality disorder are at a high risk of self-harm or suicide. By focusing on preventing self-inflicted harm, the nurse ensures the client's safety and addresses the most immediate threat. Encouraging support group attendance (
A) and discussing assertive behavior (
B) are important but not as critical as safety. Assisting the client in maintaining awareness of thoughts and feelings (
D) is valuable for therapy but does not address the immediate risk of harm.
Question 2 of 5
A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, 'I think my blackouts are actually caused by low blood sugar.' The nurse should recognize the client is using which of the following defense mechanisms?
Correct Answer: D
Rationale: The correct answer is D: Rationalization. The client is using rationalization by attributing their blackouts to low blood sugar instead of acknowledging the possibility of dissociative identity disorder. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical explanations to avoid facing uncomfortable truths. In this scenario, the client is rationalizing their blackouts as a result of low blood sugar, which is a more socially acceptable reason compared to accepting the diagnosis of dissociative identity disorder.
Suppression (
A) involves consciously pushing unwanted thoughts or feelings out of awareness. Sublimation (
B) is redirecting unacceptable impulses into socially acceptable activities. Projection (
C) is attributing one's own thoughts or feelings onto others. In this case, the client is not using these defense mechanisms.
Question 3 of 5
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client's spiritual needs?
Correct Answer: A
Rationale: The correct answer is A: Offer to contact the client's spiritual advisor if they have one. This is the most appropriate action because it acknowledges and respects the client's spiritual beliefs and provides support in accessing spiritual guidance. Contacting the client's spiritual advisor can help the client navigate their grief process in a way that aligns with their spiritual beliefs and values.
Choice B is incorrect because changing the subject when the client expresses anger can invalidate their emotions and hinder the grieving process.
Choice C is incorrect as it may isolate the client further, leading to increased feelings of spiritual inadequacy.
Choice D is incorrect as encouraging the client to internalize their feelings can be detrimental to their emotional well-being. It is important to validate and support the client's emotions during the grieving process.
Question 4 of 5
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Obtain a prescription for seclusion within 30 minutes. This action is crucial as seclusion should only be implemented with a physician's order to ensure the client's safety and rights are protected. The nurse must promptly obtain this order to ensure the client's needs are met in a timely manner.
Choice A is incorrect because documenting the client's behavior every 60 minutes does not address the immediate need for a physician's order for seclusion.
Choice B is incorrect as there is no specific time limit for seclusion, and it should only be ended with a physician's approval.
Choice D is incorrect as monitoring vital signs every 4 hours is important but not as urgent as obtaining the seclusion prescription.
Question 5 of 5
A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?
Correct Answer: A
Rationale: The correct answer is A: Identify the client's current stage of grief. This is the priority because understanding the client's current stage of grief allows the nurse to tailor interventions accordingly. By assessing the client's stage, the nurse can provide targeted support and interventions to help the client process and cope with their grief effectively.
Choice B is incorrect because while informing the client about expected feelings is important, it is not the priority over assessing the current stage of grief.
Choice C is incorrect as physical activities may not be suitable or helpful depending on the client's stage of grief.
Choice D is also incorrect as discussing the use of a spiritual grief counselor should come after assessing the client's current needs and preferences.