ATI RN
Behavioral Health Nursing Questions
Question 1 of 5
A nurse is caring for a patient diagnosed with anorexia nervosa. The patient states, 'I need to lose more weight.' What is the priority nursing diagnosis for this patient?
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image. This is the priority nursing diagnosis because the patient's statement indicates a distorted perception of their own body, which is a core issue in anorexia nervosa. Addressing the patient's distorted body image is crucial in promoting positive self-perception and working towards recovery. Incorrect choices: A: Imbalanced nutrition: Less than body requirements - While this is a common concern in anorexia nervosa, the patient's statement about needing to lose more weight indicates a deeper psychological issue that needs immediate attention. B: Ineffective coping - While coping strategies are important, the primary focus should be on addressing the distorted body image in this case. D: Risk for injury - While anorexia nervosa can lead to physical complications, the patient's statement does not directly suggest an immediate risk for injury, making this option less of a priority compared to addressing the distorted body image.
Question 2 of 5
A nurse is assessing a patient diagnosed with major depressive disorder. The patient states, 'I feel like I have failed in everything I've done.' What is the priority nursing intervention?
Correct Answer: C
Rationale: Correct Answer: C - Assess the patient for suicidal thoughts and plans. Rationale: 1. Suicidal ideation is a serious concern in major depressive disorder. 2. It is crucial to assess the patient's current risk for self-harm. 3. Assessing for suicidal thoughts and plans allows for appropriate safety measures to be implemented. 4. This intervention addresses the immediate safety of the patient. Summary: - Option A focuses on positivity but does not address the risk of harm. - Option B offers reassurance but does not directly address suicidal ideation. - Option D suggests a treatment modality but does not address the immediate safety concern.
Question 3 of 5
The desired outcome for a patient experiencing insomnia is, 'Patient will sleep for a minimum of 5 hours nightly within 7 days.' At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as
Correct Answer: D
Rationale: The correct answer is D: never demonstrated. This is because the patient did not meet the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Despite taking a 2-hour afternoon nap, the average nightly sleep is still below the target. Choice A, B, and C are incorrect because the patient did not consistently, often, or sometimes demonstrate the desired outcome as specified in the question. The key factor in determining the correct answer is comparing the actual outcome (4 hours of sleep) to the desired outcome (minimum of 5 hours of sleep).
Question 4 of 5
A nurse is caring for a patient diagnosed with bulimia nervosa. The patient states, 'I feel so ashamed after I eat.' What is the most appropriate response by the nurse?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Empathy: By acknowledging the patient's feelings of shame, the nurse validates their emotions and shows understanding. 2. Therapeutic Communication: Expressing empathy creates a supportive environment and encourages the patient to open up about their struggles. 3. Building Trust: Acknowledging the patient's emotions helps in building a trusting nurse-patient relationship, essential for effective care. 4. Encouraging Help-Seeking Behavior: By stating "we are here to help you," the nurse encourages the patient to seek assistance and engage in treatment. Summary: A: This response oversimplifies the issue and doesn't address the patient's emotional needs. C: Ignoring the patient's feelings and focusing solely on eating habits may be counterproductive. D: This response lacks empathy and fails to provide the necessary support for the patient's emotional well-being.
Question 5 of 5
A patient newly diagnosed as HIV-positive seeks the nurse's advice on how to reduce the risk of infections. The patient says, 'I went to church years ago and I was in my best health then. Maybe I should start going to church again.' Which response will the nurse offer?
Correct Answer: C
Rationale: The correct answer is C because research indicates that spiritual practices can positively impact immune system function and coping abilities, which can help reduce the risk of infections in HIV-positive individuals. This response acknowledges the potential benefits of spiritual practices on health outcomes. Choice A is incorrect as it dismisses the potential influence of spiritual practices on health and instead attributes the patient's previous good health to youth and strength. Choice B is incorrect because it acknowledges the benefit of social support but does not directly address the potential health benefits of spiritual practices. Choice D is incorrect as it focuses solely on the risk of infections from attending church without considering the potential positive effects of spiritual practices on health.