ATI RN
Nclex Mental Health Practice Questions Questions
Question 1 of 5
A patient has been admitted to the detoxification unit after binge drinking. Even though the patient is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
Correct Answer: C
Rationale: Correct Answer: C: Risk for Other-Directed Violence related to alcohol withdrawal Rationale: 1. The patient is exhibiting combative behavior and altered thought processes, indicating potential for violent behavior towards others. 2. Other-directed violence encompasses harm towards others, making it a priority to ensure the safety of both the patient and others. 3. This diagnosis addresses the immediate safety concern and allows for interventions to prevent harm to others. Incorrect Choices: A: Risk for Injury - Focuses on self-injury, not directed towards others. B: Risk for Self-Mutilation - Similar to choice A, does not address potential harm towards others. D: Risk for Delayed Development - Not relevant to the current situation of altered thought processes and combative behavior.
Question 2 of 5
The nurse is assessing a client who is diagnosed with borderline personality disorder. Which client statement indicates the client is at risk for self-injurious behavior?
Correct Answer: D
Rationale: The correct answer is D because impulsivity is a common characteristic of borderline personality disorder and can lead to self-injurious behaviors. The statement "It is almost as if as soon as I think of doing something, I immediately do it" indicates a lack of impulse control and potential for engaging in harmful behaviors without considering consequences. A: This statement expresses feelings of depression but does not directly indicate self-injurious behavior risk. B: This statement suggests a lack of autonomy but does not directly indicate self-injurious behavior risk. C: This statement describes dissociation, which is common in borderline personality disorder but does not directly indicate self-injurious behavior risk. In summary, choice D is the correct answer as it directly implies impulsivity and potential for self-injurious behavior, while the other choices do not clearly indicate this risk.
Question 3 of 5
The nurse is assessing the sleep patterns of a 70-year-old female client with a mental disorder. Based on the knowledge of circadian rhythms and the influence of age, which of the following would the nurse anticipate that the client would report about her sleep pattern?
Correct Answer: B
Rationale: The correct answer is B because as individuals age, their circadian rhythm tends to shift, resulting in feeling sleepier at night and more alert in the morning. This is known as advanced sleep phase syndrome, common in older adults. Choice A is incorrect as age-related changes in circadian rhythm lead to feeling differences in morning and evening. Choice C is incorrect as older adults often experience difficulty staying asleep rather than feeling sleepy in the morning. Choice D is incorrect as the quality and quantity of sleep become more important with age due to changes in sleep patterns.
Question 4 of 5
A couple is concerned that the husband's father may be developing depression. In questioning the couple, which of the following statements would support their concern?
Correct Answer: C
Rationale: Step 1: The correct answer is C because it indicates a prolonged period of over 2 months of persistent symptoms such as crying, inability to eat or sleep. Step 2: This prolonged duration of symptoms is indicative of a potential depressive episode. Step 3: The inability to eat or sleep are common symptoms of depression. Step 4: This statement highlights a significant change in the father's behavior following the mother's death, suggesting a possible depressive disorder. Summary: Choice A: The duration of symptoms is not as prolonged as in choice C. Choice B: While agitation and anxiety can be symptoms of depression, they are not as specific or severe as the symptoms in choice C. Choice D: The timeframe of symptoms mentioned here is not as long as in choice C, making it less concerning for depression.
Question 5 of 5
A nurse is working with a client who is a survivor of violence on developing a safety plan. Which of the following would the nurse address first?
Correct Answer: B
Rationale: The correct answer is B, recognizing the signs of danger, as it is crucial to be able to identify potential threats before devising an escape plan or identifying safe places. By recognizing signs of danger, the client can proactively assess risky situations and take necessary precautions. This step is vital in ensuring the client's safety and preventing harm. Option A, devising an escape route, would be ineffective if the client cannot recognize the signs of danger to know when to use the route. Option C, identifying a safe place to hide, is not as effective as recognizing signs of danger since hiding may not always be a viable solution. Option D, identifying a signal to indicate it is safe to leave, would not be effective if the client cannot accurately assess when it is safe to leave. Recognizing signs of danger is the foundational step in creating a comprehensive safety plan.