ATI RN
Assessing Health Behavior Nursing Questions
Question 1 of 5
When the nurse asks the client to restate the following in his or her own words, which sensorium and intellectual process is the nurse attempting to identify? The nurse states, 'A stitch in time saves nine.'
Correct Answer: D
Rationale: When the nurse states, 'A stitch in time saves nine,' and asks the client to restate it in his or her own words, the nurse is assessing the client's ability to use abstract thinking. The client's orientation is recognizing person, place, and time. The client's memory, both recent and remote, can be assessed by asking the client questions that have verifiable answers. The client's ability to concentrate can be assessed by asking the client to perform certain tasks including spelling the word 'world' backward.
Question 2 of 5
Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following?
Correct Answer: C
Rationale: The client displayed ideas that were loosely associated to one another. Tangential thinking is manifested by wandering off the topic and never providing the information requested. Ideas of reference are the client's inaccurate interpretation that general events are personally directed to him or her. Word salad is a flow of unconnected words that convey no meaning to the listener.
Question 3 of 5
A 22-year-old client has been manipulative of staff and disruptive in the milieu. Although she is not dangerous to herself or others, she has created problems on the unit and clearly is not making progress. The nurses offer prescribed medication, but she consistently refuses 'any drugs.' The staff realizes that legally this client can
Correct Answer: D
Rationale: The client maintains the right to refuse treatment even if it is needed when she is not dangerous to herself or others. If a client able to give consent, she cannot be coerced into doing so, have her family sign permission for her, or be committed by the family to receive treatment unless she is a danger to herself or others.
Question 4 of 5
Which of the following are criteria that must be adhered to when instituting the short-term use of restraint or seclusion? Select one that does not apply.
Correct Answer: B
Rationale: Short-term use of restraint or seclusion is permitted only when the client is imminently aggressive and dangerous to himself or herself or to others, and all other means of calming the client have been unsuccessful. The nurse must frequently contact the client and reassure the client that restraint is a restorative, not a punitive, procedure. If the client is physically and emotionally self-controlled, there is no reason for the client to be restrained or secluded.
Question 5 of 5
A nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparents—so helpless. Which response is the nurse demonstrating?
Correct Answer: B
Rationale: Countertransference is the nurse’s emotional response to a patient based on the nurse’s unconscious needs, conflicts, or past experiences. Here, the nurse’s sadness and comparison to a grandparent indicate a personal emotional reaction rather than a patient-driven one. Transference involves the patient’s feelings toward the nurse, not the nurse’s toward the patient. Catastrophic reaction refers to an exaggerated patient response to stress, and defensive coping reaction is a patient mechanism, not a nurse response.