ATI RN
Behavioral Health Nurse Certification Questions
Question 1 of 5
A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?
Correct Answer: D
Rationale: The correct answer is D: Pupillary dilation. In acute fentanyl toxicity, the opioid can cause miosis (pupillary constriction) initially, followed by pupillary dilation as a sign of overdose. This occurs due to the impact of opioids on the autonomic nervous system. Elevated heart rate (choice A) and hypertension (choice B) are not typical adverse effects of fentanyl toxicity; instead, bradycardia and hypotension are more common. Tachypnea (choice C) is also unlikely as opioids tend to cause respiratory depression rather than increased respiratory rate. Pupillary dilation (choice D) is the most indicative sign of acute fentanyl toxicity and should alert the nurse to the seriousness of the situation.
Question 2 of 5
A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate that the client's problems arise from issues of role definition and grief and will frame solutions in interpersonal terms. This therapy is useful for those with avoidant personality disorder who seek the approval of others and fear rejection.
Correct Answer: D
Rationale: The correct answer is D: Interpersonal therapy. This therapy focuses on addressing issues related to interpersonal relationships and communication. For clients with avoidant personality disorder who fear rejection and seek approval, interpersonal therapy helps them navigate their difficulties in forming and maintaining relationships. It also addresses issues of role definition and grief, which are common challenges for individuals with this disorder. Antipsychotic medications (A) are typically used to treat psychotic disorders, not personality disorders like avoidant personality disorder. Dialectical behavior therapy (B) is more commonly used for borderline personality disorder, not avoidant personality disorder. Antidepressant medications (C) may be prescribed for individuals with avoidant personality disorder who also have comorbid depression, but they do not specifically target the interpersonal issues and fear of rejection that are core features of this disorder.
Question 3 of 5
A nurse is caring for a client who has dementia and observes that the client becomes stressed and requires assistance and monitoring when their family visits. When the family leaves the room, the client returns to baseline and the deficits are gone. Using the Functional Assessment Stage Tool, the nurse should identify that the client is in which of the following stages of Alzheimer's disease?
Correct Answer: B
Rationale: The correct answer is B: Incipient. In the incipient stage of Alzheimer's disease, individuals may still be able to function independently but exhibit subtle memory deficits. In this scenario, the client's deficits are not always present and only occur when the family visits, suggesting a situational trigger for stress. This aligns with the early stages of Alzheimer's where symptoms may fluctuate. Choices A, C, and D are incorrect because in severe, moderate, and mild stages of Alzheimer's disease, the deficits are more persistent and do not improve when triggers are removed.
Question 4 of 5
Which scenario is an example of a tort?
Correct Answer: D
Rationale: The correct answer is D because giving an as-needed dose of an antipsychotic drug without proper assessment or authorization can be considered a tort, specifically the tort of battery. This is because the nurse is administering medication without consent, which violates the patient's right to autonomy and bodily integrity. It can also result in harm or adverse effects to the patient. Choice A is not a tort as it relates to a delay in completing a plan of care, which may be a violation of hospital policies but not a legal tort. Choice B involves appropriate care and assessment based on the patient's history and symptoms, so it is not a tort. Choice C is related to changes in patient status based on improvement in symptoms, which is not a tort as long as it is done following proper protocols and procedures.
Question 5 of 5
A patient diagnosed with major depressive disorder repeatedly tells staff members, 'I have cancer. It's my punishment for being a bad person.' Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
Correct Answer: B
Rationale: The correct answer is B: Risk for suicide. In this scenario, the patient's belief of having cancer as punishment indicates a distorted thought pattern and extreme guilt, which can increase the risk of suicidal ideation. Addressing the risk for suicide is the priority to ensure the patient's safety. Option A, powerlessness, may be relevant but is not the immediate concern. Option C, stress overload, is not as critical as the risk for suicide. Option D, spiritual distress, is not the priority compared to ensuring the patient's safety from self-harm.