ATI RN
Behavioral Health Nursing Questions
Question 1 of 5
A nurse in an emergency department is assessing a client who has a personality disorder and reports that they recently used illicit drugs. Which of the following screening tools should the nurse use to determine if the client has recently used an illicit substance?
Correct Answer: A
Rationale: The correct answer is A: Toxicology test. This test directly screens for the presence of illicit substances in the client's system, providing objective evidence of recent drug use. It is essential in the emergency department setting to determine the client's current physiological state accurately. Other choices are incorrect because: B: MMPI and C: Eysenck Personality Inventory are psychological assessment tools that focus on personality traits and psychopathology, not substance use. D: Personality Diagnostic Questionnaire is used to assess personality disorders, not substance use. Therefore, the toxicology test is the most appropriate tool in this scenario to determine recent illicit drug use.
Question 2 of 5
A patient diagnosed with severe and persistent mental illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Encourage mutual goal setting. This intervention is crucial as it empowers the patient to take an active role in their care, promoting autonomy and self-efficacy. By involving the patient in setting goals, it helps them regain a sense of control and combat feelings of powerlessness. It also fosters a collaborative relationship between the patient and the healthcare team, enhancing trust and engagement in the treatment process. Incorrect choices: B: Verbally communicate empathy - While empathy is important, it does not directly address the issue of powerlessness. C: Reinforce participation in activities - While participation in activities can be beneficial, it may not address the underlying issue of powerlessness. D: Demonstrate an accepting attitude - While acceptance is important, it may not empower the patient to actively participate in their care and address feelings of powerlessness.
Question 3 of 5
Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice?
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer (A): 1. Professional standards of nursing care are based on ethical principles and guidelines. 2. Nurses have a duty to provide safe and quality care, regardless of institutional policies. 3. Individual nurses are accountable for their actions and cannot solely rely on institutional policies. 4. Upholding professional standards ensures patient safety and ethical practice. Summary of why other choices are incorrect: - B: Agency policies are important but do not override professional standards of care. - C: Leaving the premises may not always be necessary; addressing concerns with the supervisor is a more appropriate initial step. - D: Judicial interpretation is not relevant to individual nursing practice within the institution.
Question 4 of 5
A patient's employment is terminated, and major depressive disorder develops shortly afterward. The patient says to the nurse, 'I'm not worth the time you spend with me. I'm the most useless person in the world.' Which nursing diagnosis applies?
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Situational low self-esteem. The patient's statement reflects a negative self-perception related to the recent termination of employment, indicating situational low self-esteem. This diagnosis focuses on a specific event affecting self-worth. Choice A, Powerlessness, would be more appropriate if the patient expressed a lack of control in their situation. Choice B, Defensive coping, would apply if the patient was using defensive mechanisms to protect themselves from the emotional impact of job loss. Choice D, Disturbed personal identity, would be relevant if the patient had a significant disruption in self-concept beyond just low self-esteem.
Question 5 of 5
Which statement by a patient diagnosed with schizophrenia demonstrates delusional thinking?
Correct Answer: A
Rationale: The correct answer is A because the statement reflects a clear false belief (delusion) that the television is sending secret messages to the patient. This belief is not based on reality or evidence. In contrast, choices B, C, and D do not demonstrate delusional thinking. Choice B expresses general distrust, choice C suggests a feeling of being watched due to a perceived special status, and choice D indicates auditory hallucinations, not delusional thoughts. Delusions are fixed, false beliefs that are not culturally accepted or based on factual evidence.