ATI RN
Behavioral Health Nursing Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A patient diagnosed with bipolar disorder is experiencing acute mania. Which of the following interventions should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A because ensuring the patient is in a safe environment and monitoring for physical harm is the top priority during acute mania. This intervention focuses on preventing any harm to the patient or others, which is crucial in managing acute mania. It prioritizes safety and can help prevent any potential dangerous situations. Encouraging group activities (choice B) may not be effective during acute mania as the patient may not be able to participate safely. Administering a sedative (choice C) without ensuring safety first can lead to potential risks. Offering medication (choice D) should be done after ensuring the patient's safety.