A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?

Questions 19

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2019 ATI Mental Health Proctored Exam Questions

Question 1 of 5

A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?

Correct Answer: D

Rationale: The correct answer is D: Impaired verbal communication. The patient's inability to speak, make eye contact, and focus on the speaker indicates a communication issue. Impaired verbal communication relates to difficulty expressing thoughts, feelings, or needs. The patient's behavior aligns with this diagnosis as they are mute, inattentive, and not making eye contact. Defensive coping (A) involves protecting oneself from emotional pain. Decisional conflict (B) pertains to uncertainty about choices. Risk for other-directed violence (C) involves potential harm to others, which is not evident in the scenario. Thus, D is the most appropriate nursing diagnosis.

Question 2 of 5

The nurse is caring for a patient who has been under severe stress while caring for her elderly mother who is in the advanced stages of Alzheimer's disease. The nurse explains that the patient is adapting to the stress she is experiencing because of which of the following?

Correct Answer: A

Rationale: Correct Answer: A: Ability to survive in the midst of severe stress Rationale: 1. The patient is under severe stress due to caring for her mother with Alzheimer's disease. 2. Adaptation to stress involves the ability to survive and cope with challenging situations. 3. Surviving severe stress indicates the patient's resilience and ability to endure difficult circumstances. 4. This choice best reflects the patient's capacity to manage and withstand the stress she is facing. Summary: B: Acceptance of others' help in caring for her mother - This choice focuses on receiving help from others, which may not directly relate to the patient's ability to adapt to stress. C: Success at being able to solve problems - While problem-solving skills are valuable, adaptation to stress goes beyond just solving problems. D: Capability in setting reasonable personal goals - Setting goals is important but may not directly address the patient's adaptation to severe stress.

Question 3 of 5

Johnny is twelve-year-old boy who has had an increase in aggressive behaviors, picking fights with other students at his school. Johnny's mother calls his doctor's office to ask if there is medication to help decrease these behaviors. After gathering more information about the recent increase in Johnny's outbursts, what is the best response from the nurse?

Correct Answer: B

Rationale: The correct answer is B: Medication may not be indicated right away; there are other options. Rationale: 1. Medication should not be the first line of intervention for behavior issues in children. 2. It is important to explore other options such as therapy, counseling, behavior modification techniques. 3. Understanding the root cause of Johnny's behavior is crucial before considering medication. 4. Rushing into medication without exploring other avenues may not address the underlying issues. Summary: A: Allowing more freedom at home could potentially worsen Johnny's behavior by reinforcing the negative actions. C: Telling Johnny his behavior is unacceptable without addressing the underlying cause may not effectively reduce his aggression. D: Allowing Johnny to skip school is not a solution; addressing the behavior and providing appropriate support is essential.

Question 4 of 5

The nurse is counseling a parent whose child has a communication disorder. Which of the following would the nurse emphasize when teaching the parent about this disorder?

Correct Answer: B

Rationale: The correct answer is B: Initiating conversations with the child frequently. This is important as it helps the child practice communication skills and improves their confidence. By engaging in regular conversations, the child gets more opportunities to develop their speech and language abilities. Option A is incorrect as solely focusing on nonverbal activities may neglect the child's speech development. Option C is incorrect as stopping the child's conversation when stuttering begins can lead to frustration and hinder progress. Option D is incorrect as medication is not typically the primary treatment for communication disorders in children.

Question 5 of 5

Which nurse would qualify as a fact witness in a case dealing with a physically abused young child?

Correct Answer: C

Rationale: The correct answer is C, an emergency room nurse. In cases of physical abuse, an emergency room nurse who directly treated the child and observed the injuries qualifies as a fact witness. They can provide firsthand accounts of the child's condition and the circumstances surrounding the incident. A psychiatric nurse (A) may not have direct knowledge of the physical abuse, focusing on mental health aspects. A sexual assault nurse examiner (B) specializes in sexual assault cases, not physical abuse. A pediatric intensive care unit nurse (D) may have limited interaction with the child and lack direct knowledge of the abuse.

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