ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?
Correct Answer: C
Rationale: Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. A nurse breaking silences is not a principle related to silences. It is inaccurate to say that patients withdraw during long silences or that silence helps patients know that they are understood. Feedback helps patients know they have been understood.
Question 2 of 5
A nurse is caring for a patient diagnosed with major depressive disorder. The patient states, 'I have no hope for the future. I can't see any way out of this.' What is the priority nursing intervention?
Correct Answer: B
Rationale: In this scenario, the priority nursing intervention is option B) Assess the patient for suicidal thoughts and intentions. This is the correct choice because the patient's statement about having no hope for the future and not seeing a way out indicates a high level of hopelessness, which is a significant risk factor for suicide in individuals with major depressive disorder. Option A) Encouraging the patient to set realistic goals for the future may be important for the patient's overall mental health, but in this situation, assessing for immediate safety concerns takes precedence. Option C) Offering positive affirmations may provide some comfort to the patient, but it does not address the serious risk of suicide that the patient's statement implies. Option D) Suggesting engagement in physical activities is a helpful intervention for managing depression symptoms, but it does not directly address the patient's expression of hopelessness and potential suicidal ideation. Educationally, it is crucial for nurses to recognize and prioritize interventions based on the level of risk to the patient. Assessment of suicidal ideation is a fundamental aspect of caring for individuals with mental health disorders, and immediate action is required to ensure patient safety. This case underscores the importance of thorough assessment and timely intervention in addressing mental health crises.
Question 3 of 5
A nurse is assessing a patient diagnosed with schizophrenia who is exhibiting disorganized speech. The patient states, 'I want to eat a chicken sandwich but the moon is yellow and all the words are backwards.' What is the most appropriate nursing intervention?
Correct Answer: A
Rationale: The most appropriate nursing intervention in this scenario is option A) Encourage the patient to focus on the present and engage in a simple conversation. This approach is grounded in therapeutic communication techniques for individuals with schizophrenia experiencing disorganized speech. By encouraging the patient to focus on the present and engage in a simple conversation, the nurse can help the patient reorient to reality and potentially decrease the disorganization in their speech. Option B) Redirect the conversation to focus on topics of interest to the patient may not be effective in this situation as it does not address the patient's disorganized speech directly or help them reorient to reality. Option C) Ask the patient to clarify their speech and provide feedback could potentially increase the patient's confusion and distress, as individuals with schizophrenia may struggle to clarify their disorganized thoughts and speech. Option D) Acknowledge the patient's speech and allow them to express their feelings, while important in building rapport and showing empathy, may not be the most beneficial intervention in this case where the patient's speech is disorganized and disconnected from reality. Educationally, it is crucial for nurses to understand the principles of therapeutic communication when working with patients with schizophrenia. By using techniques like focusing on the present and engaging in simple conversations, nurses can support patients in managing their symptoms and improving their communication skills.
Question 4 of 5
Documentation in a patient's chart shows, 'Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.' Which analysis is most accurate?
Correct Answer: C
Rationale: When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.
Question 5 of 5
The adult child of a patient diagnosed with major depressive disorder asks, 'Do you think depression and physical illness are connected? Since my father's death, my mother has had shingles and the flu, but she's usually not one who gets sick.' Which answer by the nurse best reflects current knowledge?
Correct Answer: D
Rationale: The correct answer best explains the research. Research supports a link between negative emotions and/or prolonged stress and impaired immune system functioning. Activation of the immune system sends proinflammatory cytokines to the brain, and the brain in turn releases its own cytokines that signal the central nervous system to initiate myriad responses to stress. Prolonged stress suppresses the immune system and lowers resistance to illness. Although the adult child may be more aware of issues involving the mother, the pattern of illnesses described may be an increase from the mother's baseline.