ATI RN
Behavioral Health Nursing Questions
Question 1 of 5
A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the client states that they have been using cocaine at least once daily for the past 6 months. The nurse is collecting which of the following types of data from the client's account?
Correct Answer: A
Rationale: The correct answer is A: Subjective. Subjective data is information provided by the client, based on their personal experiences and feelings. In this scenario, the client's statement about using cocaine daily is their personal account, making it subjective data. The nurse is gathering this information directly from the client's perspective. Summary: B: Secondary data refers to information collected from sources other than the client, such as medical records or research studies. C: Historical data pertains to past events and may include information about the client's substance use history, but it does not capture the client's current experiences as directly as subjective data. D: Objective data is measurable and observable, typically collected through physical assessments or laboratory tests. In this case, the client's statement about cocaine use is not objective data as it is based on their personal account.
Question 2 of 5
A nurse is providing care to a client who has acute stress disorder. Which of the following client statements is consistent with this disorder?
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates experiencing a traumatic event, having nightmares, and the timeframe aligns with acute stress disorder symptoms. Choice A describes dissociation, more common in PTSD. Choice C suggests PTSD symptoms of flashbacks. Choice D hints at driving phobia, not specific to acute stress disorder.
Question 3 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 4 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 5 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.