ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the client's safety. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and provide appropriate intervention. This step is crucial in addressing the immediate risk of harm to the client.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is at risk of self-harm.
Choice B is incorrect as documenting the cuts is important but not the first priority when the client's safety is in question.
Choice D is incorrect as administering a tetanus antitoxin is not necessary in this situation and does not address the immediate risk of harm.
In summary, assessing the client's intent and suicide risk is the first step to ensure the client's safety, while the other choices do not address the immediate risk of self-harm.
Question 2 of 5
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
Correct Answer: C
Rationale: Unintentional weight loss in a caregiver may indicate stress and burnout.
Question 3 of 5
A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse’s priority response?
Correct Answer: C
Rationale: The correct answer is C, "Have you thought of harming yourself?" This is the priority response because the client's statement indicates possible suicidal ideation, a serious concern that requires immediate attention to ensure the client's safety. Asking directly about thoughts of self-harm allows for assessment of risk and appropriate intervention.
Choice A is incorrect as it indirectly addresses the issue and does not directly assess for potential harm.
Choice B is also incorrect as it does not address the client's suicidal ideation.
Choice D is incorrect as it focuses on the onset of feelings rather than immediate safety.
Question 4 of 5
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse’s priority?
Correct Answer: A
Rationale: The correct answer is A: Monitor for risk of self-harm. This is the priority because individuals with major depressive disorder have an increased risk of suicidal ideation and behavior. By monitoring for self-harm, the nurse can ensure the client's safety and intervene promptly if necessary. Administering antidepressants (choice
B) is important but not the priority as it may take time to show therapeutic effects. Encouraging fluid intake (choice
C) and assisting with activities of daily living (choice
D) are important aspects of care but do not address the immediate safety concern of self-harm.
Question 5 of 5
A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Encouraging inclusion of preferred foods within dietary restrictions promotes cooperation and adherence.