ATI RN
Ancc Mental Health Practice Questions Questions
Question 1 of 5
A nurse engaged in an interaction with a patient recognizes body space zones. Which of the following would the nurse identify as the individual's personal zone?
Correct Answer: A
Rationale: The correct answer is A because the personal zone is the space ranging from 18 inches to 4 feet from an individual, which falls between the intimate zone (0-18 inches) and the social zone (4-12 feet). This zone is where most interactions with acquaintances occur. Choice B is incorrect because the public zone extends beyond the social zone and is typically used for public speaking or formal presentations. Choice C is incorrect because it describes the concept of a protective or defensive space, not the personal zone. Choice D is incorrect because the concept of recognizing intruders pertains more to territoriality and is not specific to identifying personal space zones.
Question 2 of 5
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
Correct Answer: D
Rationale: The correct answer is D because exploring the impact of the mobility, sight, and hearing changes on the patient allows the nurse to address the patient's holistic needs, including spiritual distress. By understanding the patient's perspective on these changes, the nurse can provide support tailored to the patient's concerns, fostering a sense of connection and understanding. Choice A is incorrect because focusing solely on childhood religious experiences may not address the current issues the patient is facing. Choice B is inappropriate as it imposes the nurse's religious beliefs on the patient. Choice C is also incorrect as it assumes a specific religious approach without considering the patient's individual beliefs and needs.
Question 3 of 5
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (D) may impact mental health but does not directly assess immediate risk of suicide.
Question 4 of 5
A client diagnosed with bipolar disorder and experiencing mania is admitted to the inpatient psychiatric setting. During the acute phase of mania, which medication would the nurse expect to most likely administer?
Correct Answer: B
Rationale: The correct answer is B: Haloperidol lactate (Haldol). In the acute phase of mania, antipsychotic medications like haloperidol are commonly used to manage symptoms such as agitation, hyperactivity, and psychosis. Haloperidol helps to reduce dopamine activity in the brain, which can help stabilize mood and behavior during manic episodes. Lithium (A) is more commonly used for long-term mood stabilization in bipolar disorder. Fluoxetine (C) and Paroxetine (D) are selective serotonin reuptake inhibitors (SSRIs) used for depression and not recommended during mania due to the risk of worsening manic symptoms.
Question 5 of 5
A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks the nurse, 'How will this drug help me?' Which response by the nurse would be most appropriate?
Correct Answer: B
Rationale: The correct answer is B: It can help to prevent you from drinking. Disulfiram works by causing unpleasant symptoms (such as nausea, vomiting, and headache) when alcohol is consumed, acting as a deterrent to drinking. This helps the client stay sober and avoid relapse. Incorrect choices: A: It will help to cure your alcoholism - Disulfiram does not cure alcoholism but helps manage it. C: It makes the withdrawal symptoms less troublesome - Disulfiram does not address withdrawal symptoms. D: It helps to clear the alcohol out of your body - Disulfiram does not clear alcohol from the body but rather prevents its metabolism, leading to adverse effects if alcohol is consumed.