ATI RN
Behavioral Health Certification for Nurses Questions
Question 1 of 5
A patient fearfully runs from chair to chair crying, 'They're coming! They're coming!' The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?
Correct Answer: B
Rationale: A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.
Question 2 of 5
When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to
Correct Answer: C
Rationale: Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.
Question 3 of 5
A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention.
Correct Answer: A
Rationale: In this scenario, the correct intervention for the nurse is option A: Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." This response demonstrates empathy, active listening, and a commitment to providing emotional support to the grieving wife. Option B is not the best choice as it focuses on providing medical information rather than addressing the wife's emotional needs. Option C may escalate the situation by involving the healthcare provider without addressing the immediate emotional distress of the wife. Option D, while offering physical comfort, lacks verbal acknowledgment of the wife's emotional state and may not effectively address her need for emotional support in this moment of crisis. Educationally, this question highlights the importance of therapeutic communication and empathy in nursing practice, especially in sensitive and emotionally charged situations such as dealing with grief and loss. Nurses must prioritize emotional support and effective communication to build trust and rapport with patients and their families during times of distress. This intervention also aligns with the principles of patient-centered care, which emphasize holistic support for patients and their families.
Question 4 of 5
A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention?
Correct Answer: B
Rationale: The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distractor indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.
Question 5 of 5
A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.)
Correct Answer: A
Rationale: Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.