ATI RN Mental Health 2023 with NGN | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Ask the client if he intends to harm others. This is the priority action because it directly addresses the safety of the other clients. By assessing the client's intentions, the nurse can determine the level of risk and take appropriate measures to prevent harm.


Choice A is incorrect because exploring stress reduction techniques is not the immediate priority when there is a risk of harm to others.


Choice B is incorrect as role modeling healthy ways to express anger is not as urgent as addressing the current aggressive behavior.


Choice D is incorrect as making a list of things that make the client angry does not address the immediate safety concerns of the other clients.

Overall, the priority in this situation is to assess the client's intentions to prevent harm to others.

Correct Answer: A

Rationale: The correct answer is A: Autonomy. Autonomy refers to respecting the client's right to make their own decisions about their treatment. By supporting the client's refusal of medications, the nurse is upholding the principle of autonomy and acknowledging the client's right to choose what happens to their own body. This empowers the client and promotes self-determination.
Other choices are incorrect because:
B: Beneficence focuses on doing good for the client, which would involve ensuring the client receives necessary treatment.
C: Veracity relates to truth-telling, not the client's right to refuse treatment.
D: Justice is about fairness and equal treatment, not specifically related to respecting the client's autonomy.

Correct Answer: C

Rationale: The correct answer is C: Implement measures to prevent intentional self-inflicted injury. This is the priority because individuals with borderline personality disorder are at high risk for self-harm behaviors. Preventing harm to the client is the most immediate concern to ensure their safety and well-being. Encouraging support group attendance (
A) and discussing assertive behavior (
B) are important but not as critical as preventing self-injury. Assisting the client to maintain awareness of thoughts and feelings (
D) is also important but not the priority in this case.

Correct Answer: D

Rationale: The correct answer is D: Maintain a low level of environmental stimuli. Command hallucinations are auditory hallucinations that instruct the individual to perform certain actions. By reducing environmental stimuli, the nurse can help minimize triggers that may exacerbate the hallucinations. This intervention aims to create a calming and safe environment for the client, reducing the likelihood of responding to the hallucinations. Providing reassurance through touch (choice
A) may not address the underlying issue of hallucinations and could potentially be triggering. Encouraging increased socialization (choice
B) may overwhelm the client and increase stress. Avoiding eye contact (choice
C) may create a barrier in communication and trust-building. Overall, maintaining a low level of environmental stimuli is the most appropriate intervention to support the client in managing command hallucinations.

Correct Answer: C

Rationale: The correct answer is C: Focus the client on reality-based activities. This is important because redirecting the client's focus to reality-based activities can help ground them and reduce the intensity of hallucinations. By engaging in activities that connect them to the present moment, the client can gain a sense of control and stability.
Choice A is incorrect as denying the client's experience can lead to mistrust and distress.
Choice B is incorrect as avoiding direct questions may not address the client's needs effectively.
Choice D is incorrect as conveying sympathy alone may not provide the client with coping strategies.