ATI RN
ATI RN Mental Health 2023 III Questions
Question 1 of 5
A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Initiate fall precautions for the client. Lorazepam is a benzodiazepine that can cause drowsiness, dizziness, and impair coordination. Initiating fall precautions is essential to prevent the client from falling and injuring themselves due to these side effects. Instructing the client to expect ringing in the ears (choice
A) is not relevant to lorazepam administration. Placing the client in restraints (choice
B) is not appropriate and can be considered a restraint of freedom. Repeating the dose in 15 minutes (choice
C) is not recommended as it can lead to an overdose.
Question 2 of 5
A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Give the client a choice of solitary activities. Individuals with schizoid personality disorder typically prefer solitary activities and may feel uncomfortable in social situations. Providing the client with a choice of solitary activities respects their preferences and promotes their comfort and autonomy.
Explanation for incorrect options:
A: Identifying splitting behaviors is more relevant for borderline personality disorder, not schizoid personality disorder.
B: While anger management may be helpful for some clients, it is not a primary intervention for schizoid personality disorder.
D: Setting limits on the client's need for social contact goes against the nature of schizoid personality disorder, which is characterized by a preference for solitude.
Question 3 of 5
A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?
Correct Answer: B
Rationale: The correct answer is B: Geriatric Depression Scale. This test is essential for screening older adults as depression is common but often overlooked in this population. The Geriatric Depression Scale helps detect symptoms of depression, which can significantly impact the overall health and well-being of older adults. The other choices are not appropriate for screening active older adults. A: CAGE Questionnaire is used for alcohol abuse screening, not depression. C: Denver Developmental Screening Test is for children, not older adults. D: Pain Assessment in Advanced Dementia Scale is specific to assessing pain in dementia patients, not active older adults.
Therefore, the Geriatric Depression Scale is the most relevant choice for screening active older adult clients in a community clinic.
Question 4 of 5
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states, I can't stand to be touched by another person. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "I will tell your provider that you would like a treatment other than massage." This response shows the nurse's understanding and respect for the client's preferences and autonomy. It acknowledges the client's discomfort and offers an alternative solution, ensuring that the client receives appropriate care without causing further distress. Other choices are incorrect because A dismisses the client's feelings, C only addresses the physical aspect, and D might pressure the client to explain their reasons which can be uncomfortable for them.
Question 5 of 5
A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Ask the client if he intends to harm others. This is the priority action because it directly addresses the safety of other clients. By asking about the client's intentions, the nurse can assess the level of risk and take appropriate measures to prevent harm. The other choices are less critical in this situation. A (suggest making a list of things that make him angry) and D (assist in exploring techniques to reduce stress) are important in managing aggression but do not address immediate safety concerns. C (role modeling healthy ways to express anger) may be helpful in the long term but does not address the current risk of harm to others.