ATI RN
Behavioral Health Certification for Nurses Questions
Question 1 of 5
A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, 'I can't find my way home.' The patient is confused and unable to answer questions. Select the nurse's best action.
Correct Answer: D
Rationale: When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.
Question 2 of 5
A patient tells the nurse, 'I know that I should reduce the stress in my life, but I have no idea where to start.' What would be the best initial nursing response?
Correct Answer: D
Rationale: In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. Further assessment is indicated before potential solutions can be explored. Suggesting exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.
Question 3 of 5
A patient fearfully runs from chair to chair crying, 'They're coming! They're coming!' The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?
Correct Answer: B
Rationale: A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.
Question 4 of 5
A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a pm anxiolytic?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to
Correct Answer: C
Rationale: Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.