ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
The nurse records this entry in a patients progress notes: Patient escorted to unit by ER nurse at 2130. Patients clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, Let me out of here. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
A nurse assesses that a depressed patient is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the patient did not sleep well. The most probable interpretation of these data is
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
A client made threats to harm his parents if they come too close to him. The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. During this time of involuntary admission, the client retains all client rights except for which of the following?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
When is a nurse legally obligated to breach confidentiality?
Correct Answer: B
Rationale: The duty to warn a third party exists when a client threatens harm to that identifiable third party; the client's confidentiality is overridden. Answer choices A, C, and D are not situations in which confidentiality may be breached. Decisions about the duty to warn third parties usually are made by psychiatrists or by qualified mental health therapists in outpatient settings. It is not permissible for a nurse to breach confidentiality at any time a client is threatening, or becomes aggressive or violates the nurse's boundaries.
Question 5 of 5
Ensuring that the client has informed consent before agreeing to a treatment regimen displays which of the following ethical principles?
Correct Answer: D
Rationale: The nurse respects the client's autonomy through client's rights, informed consent, and encouraging the client to make choices about his or her health care. The nurse has a duty to take actions that promote the client's health (beneficence) and that do not harm the client (nonmaleficence). The nurse must treat all clients fairly (justice), be truthful and honest (veracity), and honor all duties and commitments to clients and families (fidelity).