ATI RN
ATI Custom NSG 133 Mental Health Final Exam Summer (2023) Questions
Extract:
Question 1 of 5
A home health 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: D
Rationale: The correct answer is D because significant weight loss in the partner over the past 3 months indicates caregiver role strain. This observation suggests that the partner may be neglecting their own health and well-being due to the stress and demands of caregiving for a client with Alzheimer's. The partner's weight loss is a physical manifestation of caregiver burnout and strain.
Choices A, B, and C do not directly indicate caregiver role strain. Placing locks at the top of doors (
Choice
A) is a safety measure for the client with Alzheimer's. Redirecting the client when frustrated (
Choice
B) and hiring a house cleaner (
Choice
C) are appropriate caregiving strategies to manage the client's condition and maintain a safe and clean environment.
Question 2 of 5
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?
Correct Answer: D
Rationale: The correct answer is D: Remain with the client in his room for a while. This is the most therapeutic action because it provides support, reassurance, and a sense of safety for the client experiencing panic-level anxiety. By staying with the client, the nurse can help to calm the client, offer a sense of security, and establish trust. This presence can help to prevent escalation of anxiety and provide immediate emotional support.
Choice A is incorrect because medicating the client with a sedative should not be the first-line intervention for managing anxiety.
Choice B is incorrect as joining a therapy group may be overwhelming for the client in this acute state.
Choice C is incorrect as suggesting rest in bed may not address the client's immediate emotional needs.
Choice D addresses the client's need for support and immediate emotional assistance, making it the most appropriate choice in this situation.
Question 3 of 5
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
Correct Answer: B
Rationale: The correct answer is B because the client attempting to climb out of bed and repeatedly stating she must get home is exhibiting signs of disorientation, agitation, and confusion, which are characteristic of delirium in older adults. Delirium is an acute change in mental status with fluctuating symptoms, often triggered by an underlying medical condition or medication side effects. The other choices do not specifically indicate delirium.
Choice A could be a normal response to feeling cold.
Choice C may suggest depression or apathy.
Choice D is a common behavior and not necessarily indicative of delirium.
Question 4 of 5
A nurse in an acute care mental health facility is caring for a client diagnosed with depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed, and there are no longer signs of a depressive state. Which of the following is an appropriate action by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's whereabouts at all times.
Rationale:
1. Sudden change in mood from depression to cheerfulness can indicate a potential shift towards suicidal ideation.
2. Monitoring the client's whereabouts ensures safety and prevents self-harm.
3. It is crucial to maintain close observation during such transitions to provide appropriate care.
Incorrect
Choices:
A: Encouraging family outings may pose a risk if the client is not stable.
B: Rewarding behavior without understanding the underlying cause can be counterproductive.
C: Asking why the behavior changed may not provide immediate insight into the client's safety.
Question 5 of 5
A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
Correct Answer: C
Rationale: The correct answer is C: Assess client's nutritional status. The first priority for the client should be to assess her nutritional status because the significant weight loss may indicate malnutrition or an underlying health issue. By assessing the client's nutritional status, the nurse can determine the client's current dietary intake, any possible deficiencies, and overall nutritional health. This information will guide the development of a personalized care plan and interventions to address the client's weight loss and distorted body image.
Choice A (Plan a therapeutic diet for the client) is incorrect because before planning a therapeutic diet, it is essential to first assess the client's nutritional status to understand her specific needs.
Choice B (Provide a structured environment for the client) is incorrect as it may not directly address the underlying cause of the weight loss and body image issues.
Choice D (Request a mental health consult) is also incorrect as assessing the client's nutritional status should come first to identify any physical factors contributing to her symptoms before addressing potential mental health concerns.