ATI RN
Theory of Health Behavior Change Questions
Question 1 of 5
The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important?
Correct Answer: D
Rationale: The correct answer is D, ensuring an unbroken chain of evidence. This is crucial in cases of sexual assault to maintain the integrity of evidence for legal proceedings. By preserving and documenting evidence properly, it increases the chances of bringing the perpetrator to justice. A: Determining the assailant's identity is important but not the nurse's role. B: Preserving the client's privacy is important but secondary to maintaining evidence. C: Identifying the extent of injury is relevant for treatment but doesn't take precedence over preserving evidence.
Question 2 of 5
Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing?
Correct Answer: C
Rationale: The correct answer is C because in a community approach setting in psychiatric nursing, the focus is on helping clients integrate into society and function independently. By demonstrating self-reliance and social adaptation, clients can better navigate their daily lives and relationships. This approach promotes long-term stability and well-being. A: While performing activities of daily living and learning crafts are important, they do not necessarily address the client's ability to adapt socially. B: Preventing aggressive behavior and monitoring medications are more individual-focused goals rather than community-oriented outcomes. D: Anxiety relief and symptom education are valuable, but they do not directly address the client's ability to adapt and function within a community setting.
Question 3 of 5
The school guidance counselor refers a family with an 8-year-old child to the mental health clinic because of the child's frequent fighting in school and truancy. Which of the following data would be a priority to the nurse doing the initial family assessment?
Correct Answer: C
Rationale: The correct answer is C because understanding the family's perception of the current problem is crucial to building rapport and developing a comprehensive assessment. By exploring the family's perspective, the nurse can gain insight into their understanding of the situation, beliefs, and potential barriers to intervention. This information can guide the nurse in formulating an appropriate plan of care that aligns with the family's values and needs. Choice A (The child's performance in school) may provide valuable information but is not as essential as understanding the family's perception of the problem. Choice B (Family education and work history) is important but not a priority at this stage. Choice D (The teacher's attempt to solve the problem) is also relevant but not as critical as understanding the family's viewpoint.
Question 4 of 5
A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication?
Correct Answer: A
Rationale: The correct answer is A because touch carries a different meaning for different individuals. This statement acknowledges the importance of individual preferences and boundaries in therapeutic touch. It emphasizes the necessity of understanding and respecting each client's unique perspective on touch. Explanation of why other choices are incorrect: B: This statement oversimplifies the use of touch in de-escalating volatile situations and does not address the complexity of touch in therapeutic communication. C: While touch can convey interest and warmth, this statement does not encompass the full range of meanings and implications that touch can have in therapeutic interactions. D: While empathy is important in conjunction with touch, this statement does not capture the diversity of meanings that touch can hold for clients.
Question 5 of 5
A client slammed a door on the unit several times. The nurse responds, "You seem angry." The client states, "I'm not angry." What therapeutic communication technique has the nurse employed and what defense mechanism is the client unconsciously demonstrating?
Correct Answer: B
Rationale: The correct answer is B: Verbalizing the implied and the defense mechanism of denial. 1. Verbalizing the implied: The nurse is reflecting the underlying emotion by stating "You seem angry," encouraging the client to explore their feelings. 2. Defense mechanism of denial: The client's statement "I'm not angry" is a form of denial, where they are unconsciously rejecting their true emotions. Summary: A: Making observations does not involve reflecting underlying emotions. Suppression involves consciously pushing down emotions, not the case here. C: Reflection involves mirroring the client's feelings, not stating an assumption. Projection is when one attributes their emotions to others. D: Encouraging descriptions of perceptions is not the same as verbalizing the implied. Displacement involves redirecting emotions to a less threatening target.