ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Intense efforts to avoid abandonment. Individuals with borderline personality disorder often exhibit fear of abandonment leading to intense efforts to avoid it. This behavior is a key feature of the disorder, characterized by frantic attempts to avoid real or imagined separation. This finding is supported by the Diagnostic and Statistical Manual of Mental Disorders criteria for borderline personality disorder.
Choices A, B, and C are incorrect because while individuals with borderline personality disorder may experience difficulty in maintaining employment, have impulsivity leading to reckless spending or hoarding, and struggle with unstable relationships, the most characteristic feature related to the fear of abandonment is intense efforts to avoid it.
Question 2 of 5
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states, 'I can’t stand to be touched by another person.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct response is D: "I will tell your provider that you would like a treatment other than massage." This is the most appropriate choice because it addresses the client's stated discomfort with being touched and shows respect for their autonomy and preferences. By communicating this to the provider, alternative treatment options can be explored that better suit the client's needs and comfort level.
A: Incorrect - Dismissing the client's concerns and assuming the anxiety will lessen is not addressing the root issue of their discomfort.
B: Incorrect - While accommodating by suggesting gloves, it does not address the core issue of the client's aversion to touch.
C: Incorrect - Asking why the client doesn't like to be touched may put them on the spot and does not provide a solution to their discomfort.
Question 3 of 5
A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?
Correct Answer: C
Rationale: The correct answer is C: "Have you noticed an increase in thirst?" This question is relevant because olanzapine, an antipsychotic medication, can cause side effects like increased thirst due to its impact on the body's regulation of water balance. By asking this question, the nurse can assess for potential side effects of the medication and monitor for dehydration.
Choices A, B, and D are less relevant as they do not directly relate to common side effects of olanzapine.
Choice A about decreased taste is not a common side effect of olanzapine.
Choice B about ringing in the ears is more likely related to ototoxic medications.
Choice D about unintentional weight loss is not a common side effect of olanzapine, which is more commonly associated with weight gain.
Question 4 of 5
A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Provide environmental cues. Delirium can be triggered by environmental factors. Providing familiar cues, such as a clock or calendar, can help orient the client and decrease confusion, promoting safety. A: Promoting decision making may overwhelm the client. B: Discouraging visits can worsen feelings of disorientation. D: Physical restraints should be avoided as they can increase agitation and risk of injury.
Extract:
Medication Administration Record
• Escitalopram 20 mg once daily
Medical History
Client is 19 years old, has severe anxiety, and was admitted to an inpatient mental health facility for observation and behavioral therapy 2 weeks ago. The client’s weight at the time of admission was 54.4 kg (120 lb). The client reported sleeping 3 to 4 hours per night due to recurrent nightmares as well as a decrease in appetite. The client’s family member stated that the client had separated themselves from friends, refused to leave their house, and picked their skin until it bled. The client’s family member stated that there is a family history of anxiety. The client reported previous participation in cognitive-behavioral therapy.
Nurses’ Notes
Client appears to be well-groomed. The client’s current weight is 54 kg (119 lb). The client states they are sleeping 5 to 6 hours per night but having an occasional nightmare. The client verbalizes decreased appetite and gastrointestinal discomfort. The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.” The client verbalizes that bullying experienced during high school has led to anxiety. The client engages in thought-stopping behavioral therapy and cognitive restructuring. The client reports taking escitalopram 20 mg daily 2 hours after breakfast.
Question 5 of 5
A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility 1 week ago.Exhibits: A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect a finding, click on the finding again.
Correct Answer: A,C,E,F
Rationale: The correct answer is A, C, E, F. A: Well-groomed appearance indicates self-care and improvement in mood. C: Verbalizing decreased appetite and gastrointestinal discomfort may indicate decreased anxiety symptoms. E: Engaging in thought-stopping therapy and cognitive restructuring shows active participation in treatment. F: Taking prescribed medication as directed indicates compliance with the treatment plan. These findings suggest the client's condition is improving.
Choices B, D, and G do not indicate clear improvement in the client's condition. B: Occasional nightmares suggest ongoing sleep disturbances. D: Statement about anxiety leaving the house indicates ongoing anxiety symptoms. G: Past bullying experiences may contribute to the client's anxiety but do not directly indicate improvement in the current condition.