ATI RN
Adult Behavioral Health Nursing Questions
Question 1 of 5
Select the most appropriate label to complete this nursing diagnosis: related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.
Correct Answer: C
Rationale: The diagnosis describes a patient who is alone due to shyness and poor social skills, fitting 'Social isolation' (Option C). This label matches the etiology (shyness, poor skills) and evidence (solitary TV watching). Option A (knowledge) is unrelated, Option B (coping) is too broad, and Option D (powerlessness) implies lack of control, not isolation.
Question 2 of 5
Which of the following would best assess a client's judgment?
Correct Answer: B
Rationale: The client's judgment can be elicited by asking the client to discuss hypothetical situations, which would indicate one's ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Counting by serial sevens and spelling words backward would assess the client's ability to concentrate. Interpreting proverbs would assess the client's abstract thinking.
Question 3 of 5
In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as
Correct Answer: C
Rationale: Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of ideas is manifested by excessive amount and rate of speech composed of fragmented or unrelated ideas. Lack of insight would be manifested by the lack of the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Tangential thinking would be manifested by wandering off the topic and never providing the information requested.
Question 4 of 5
Which of the following client situations most urgently requires the nurse to break confidentiality and warn a third party?
Correct Answer: D
Rationale: Mental health clinicians have a duty to warn identifiable third parties of threats made by clients, even if these threats were discussed during therapy sessions otherwise protected by privilege. The clinician must base his or her decision to warn others on the following: Is the client dangerous to others? Is the danger the result of serious mental illness? Is the danger serious? Are the means to carry out the threat available? Is the danger targeted at identifiable victims? Is the victim accessible?
Question 5 of 5
An adult client is put in restraints after all other attempts to reduce aggression have failed. Which of the following is required now that restraints have been instituted?
Correct Answer: B
Rationale: For adult clients, use of restraint and seclusion requires a face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint or seclusion and every 8 hours thereafter, a physician's order every 4 hours, documented assessment by the nurse every 1 to 2 hours, and close supervision of the client. Staff must monitor a client in restraints continuously on a 1:1 basis for the duration of the restraint period. A client in seclusion is monitored 1:1 for the first hour and then may be monitored by audio and video equipment.