ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend (Select all that apply)
Correct Answer: A
Rationale: The child's symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.
Question 2 of 5
Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder?
Correct Answer: A
Rationale: Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The patient's dependency needs may be evident through losses of abilities. When secondary gains are prominent, the patient is more resistant to giving up the symptom. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains.
Question 3 of 5
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable?
Correct Answer: C
Rationale: The patient demonstrates a failure to follow age-appropriate social norms and an inability to problem solve by using adaptive behaviors to meet life's demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient never mentioned hopelessness or disturbed personal identity. The problem relates to the patient's perceptions of parental behavior rather than the actual behavior.
Question 4 of 5
A patient is seen in the clinic for superficial cuts on both wrists. Initially the patient paces and sobs but after a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking:
Correct Answer: D
Rationale: A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events facilitates assessment of the precipitating event. The patient is unlikely to be able to articulate what interventions will increase feelings of comfort. "Why" questions are nontherapeutic.
Question 5 of 5
Which communication technique will the nurse use more in crisis intervention than traditional counseling?
Correct Answer: B
Rationale: The nurse working in crisis intervention must be creative and flexible in looking at the patient's situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.