ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
Question 2 of 5
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
Correct Answer: A
Rationale: The correct answer is A: Mental Status Examination (MSE). A MSE is crucial to assess cognitive function, orientation, memory, attention, and other mental aspects in older adults with suspected cognitive disorders. It helps identify cognitive deficits and guide appropriate interventions. Brief PHQ (
B) focuses on mood disorders, AIMS (
C) evaluates movement disorders, and SANS (
D) assesses negative symptoms in psychiatric disorders, which are not specific to cognitive disorders. In summary, the MSE is the most relevant tool for assessing cognitive functions in this scenario.
Question 3 of 5
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (
B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (
C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (
D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
Question 4 of 5
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
Correct Answer: C
Rationale: The correct answer is C: "I will develop a decreased physical response to alcohol." This statement indicates understanding of alcohol tolerance, where the body becomes less responsive to the effects of alcohol over time, requiring larger amounts to achieve the same effect.
Choice A is incorrect as alcohol tolerance actually leads to a decreased response, not physical changes when alcohol is not consumed.
Choice B is incorrect as alcohol tolerance does not affect the response to opiates.
Choice D is incorrect as alcohol tolerance is not a medical emergency; it is a gradual adaptation to alcohol consumption.
Question 5 of 5
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?
Correct Answer: C
Rationale: The correct answer is C: The client has lost 30 lb. This indicates maladaptive grieving as significant weight loss is a common symptom of unresolved grief. This could be due to appetite changes, neglecting self-care, or depression. Losing a considerable amount of weight can impact physical health and well-being, indicating a need for intervention.
Choices A, B, and D are not directly related to maladaptive grieving. Age (
A) and the time since the husband's death (
B) are not definitive indicators of maladaptive grieving. Difficulty sleeping (
D) can be a common symptom of grief but is not as concerning as significant weight loss in this context.