ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A newly admitted patient diagnosed with major depressive disorder has lost 20 pounds over the past month and has admitted having suicidal ideations. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
Correct Answer: C
Rationale: The priority nursing diagnosis in this scenario is C) Risk for suicide. This choice takes precedence because the patient's admission of suicidal ideations poses an immediate threat to their safety and well-being. Addressing this risk is crucial to prevent harm and ensure the patient's safety. Option A) Imbalanced nutrition: Less than body requirements is not the priority in this case, as the patient's weight loss, while concerning, is secondary to the acute risk of suicide. Option B) Chronic low self-esteem and option D) Hopelessness are important considerations in caring for a patient with major depressive disorder, but they are not as urgent as addressing the immediate risk of suicide. These nursing diagnoses can be addressed once the patient's safety is ensured. Educationally, this case underscores the critical importance of prioritizing nursing diagnoses based on the level of urgency and potential harm to the patient. Nurses must be able to quickly identify and address the most pressing issues to provide safe and effective care. In this situation, the priority is ensuring the patient's safety by addressing the risk for suicide as the primary concern.
Question 2 of 5
A nurse is caring for a patient diagnosed with generalized anxiety disorder. Which of the following interventions is most appropriate?
Correct Answer: C
Rationale: In the context of caring for a patient with generalized anxiety disorder, providing the patient with relaxation techniques to manage anxiety (Option C) is the most appropriate intervention. This is because relaxation techniques, such as deep breathing exercises, progressive muscle relaxation, and guided imagery, can help the patient calm their mind and body, reduce physiological symptoms of anxiety, and promote a sense of control over their symptoms. Encouraging the patient to confront their fears in a gradual manner (Option A) may not be suitable initially as it can exacerbate their anxiety. Administering anti-anxiety medication (Option B) is important in some cases but should not be the first-line intervention, as non-pharmacological approaches like relaxation techniques are preferred. Reassuring the patient that their anxiety is normal and will pass (Option D) may invalidate their feelings and does not provide them with concrete coping strategies. In an educational context, it is crucial for nurses to understand the importance of evidence-based interventions in managing mental health conditions like generalized anxiety disorder. By selecting appropriate interventions, nurses can support patients in effectively managing their symptoms and improving their overall well-being.
Question 3 of 5
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse what type of essential oils should be used when the client receives massage therapy to decrease anxiety. Which of the following oils should the nurse recommend?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Rosemary. Rosemary essential oil is known for its calming and stress-reducing properties, making it an ideal choice to help decrease anxiety in individuals with Alzheimer's disease during massage therapy. Eucalyptus (option A) is more commonly used for respiratory issues and may not have the same calming effects as rosemary. Frankincense (option C) is often used for relaxation and spiritual purposes, but it may not be as effective in reducing anxiety as rosemary. Cypress (option D) is known for its astringent properties and is not typically used for anxiety relief. From an educational standpoint, it is important for nurses to have a good understanding of essential oils and their therapeutic properties to provide safe and effective care to clients with Alzheimer's disease. Recommending the appropriate essential oil can enhance the overall therapeutic benefits of massage therapy and improve the client's well-being. Nurses should also consider individual preferences, allergies, and sensitivities when recommending essential oils for therapeutic use.
Question 4 of 5
A nurse is caring for a client who has post-traumatic stress disorder and is considering prolonged exposure therapy. The client asks, 'How does this therapy work?' Which of the following responses by the nurse accurately describes this type of therapy?
Correct Answer: B
Rationale: The correct answer is B) A therapist helps you safely and gradually face memories or situations related to your trauma that evoke fear. Prolonged exposure therapy is a type of cognitive-behavioral therapy commonly used to treat post-traumatic stress disorder (PTSD). This therapy works by gradually exposing the individual to their traumatic memories or situations in a safe and controlled environment. By facing these experiences repeatedly over time, the individual can learn to process and reduce the fear associated with the trauma, ultimately leading to a decrease in PTSD symptoms. Option A is incorrect because it describes eye movement desensitization and reprocessing (EMDR) therapy, which involves focusing on eye movements while recalling traumatic experiences, but it does not involve exposure to the trauma itself. Option C describes talk therapy or psychotherapy focused on self-awareness and behavior change, which is not specific to the exposure-based approach of prolonged exposure therapy for PTSD. Option D describes cognitive therapy, which focuses on understanding and changing thought patterns and behaviors but does not involve exposure to traumatic memories as in prolonged exposure therapy. In an educational context, it is crucial for nurses to understand different types of therapy for mental health conditions like PTSD to provide accurate information to clients. Understanding the rationale behind each therapy helps nurses support clients in making informed decisions about their treatment options.
Question 5 of 5
A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient states, 'I don't need to sleep. I feel great!' Which of the following is the priority nursing diagnosis for this patient?
Correct Answer: B
Rationale: In this scenario, the priority nursing diagnosis for a patient with bipolar disorder in the manic phase stating "I don't need to sleep. I feel great!" is option B) Risk for injury related to impulsive and reckless behavior. This is the correct choice because during the manic phase, individuals often engage in risky behaviors due to their elevated mood and decreased impulse control. The patient's statement indicates a lack of recognition of the need for sleep, which can lead to increased impulsivity and potential harm. Option A is incorrect as disturbed sleep pattern, though important, is secondary to the immediate risk of injury. Option C is incorrect because while imbalanced nutrition may occur in bipolar disorder, the safety concern of impulsive behavior takes precedence. Option D is incorrect as ineffective coping is a concern, but the immediate risk of injury due to reckless behavior is the priority in this case. Educationally, understanding the hierarchy of nursing diagnoses in managing patients with bipolar disorder is crucial. Prioritizing safety concerns and addressing immediate risks is fundamental in providing effective care for individuals experiencing manic episodes. It is essential for nurses to recognize and respond to potential harm that may result from impulsive behaviors during the manic phase.