ATI RN
Behavioral Health Nursing Questions
Question 1 of 5
A patient says to the nurse, 'I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well.' Which response should the nurse use to clarify the patient's comment?
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the ambiguity in the patient's statement by seeking clarification on the term "stoned." This allows the nurse to gain a better understanding of the patient's experience, ensuring effective communication and assessment. Choice A is incorrect as it assumes the patient was uncomfortable with the dream content without confirming it. Choice B relates the nurse's experience, which does not help clarify the patient's statement. Choice C assumes the patient's issue is related to sleep quality, which may not be the case.
Question 2 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 3 of 5
A nurse is working with a patient diagnosed with schizophrenia. The patient reports hearing voices and states, 'The voices tell me to hurt myself.' What is the priority nursing intervention?
Correct Answer: A
Rationale: The correct answer is A because the priority in this situation is to ensure the patient's safety. By ensuring the patient is in a safe environment and assessing for suicidal thoughts and behaviors, the nurse can prevent harm to the patient. Encouraging reality-based activities (B) and providing reassurance (C) may not address the immediate risk of harm posed by the voices. Asking about the content of the voices and validating their experiences (D) may be important for understanding the patient's perspective, but safety should come first.
Question 4 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 5 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).