ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 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). This is a crucial part of the assessment for a suspected cognitive disorder in older adults. The MSE evaluates cognitive functions such as orientation, memory, attention, language, and executive functions. It helps in identifying any cognitive deficits and provides a baseline for monitoring changes over time.
Brief Patient Health Questionnaire (Brief PHQ) (
B), Abnormal Involuntary Movements Scale (AIMS) (
C), and Scale for Assessment of Negative Symptoms (SANS) (
D) are not appropriate for assessing cognitive disorders. The Brief PHQ is used for screening depression, AIMS for monitoring movement disorders, and SANS for assessing negative symptoms in psychiatric disorders. These tools do not directly evaluate cognitive functions.
Question 2 of 5
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
Correct Answer: C
Rationale: The correct answer is C: Major depressive disorder. This diagnosis presents the greatest risk for suicide due to the severity and intensity of depressive symptoms, including pervasive feelings of hopelessness, worthlessness, and suicidal ideation. Clients with major depressive disorder often experience significant impairment in daily functioning, making them more vulnerable to suicidal behavior. Other choices like premenstrual dysphoric disorder (
A), seasonal affective disorder (
B), and persistent depressive disorder (
D) may also have depressive symptoms but are generally less severe and do not typically carry the same level of suicide risk as major depressive disorder.
Question 3 of 5
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). NMS is a rare but life-threatening side effect of antipsychotic medications like haloperidol. The client's symptoms of high fever, elevated blood pressure, and muscle rigidity are classic signs of NMS. The nurse should suspect NMS due to the acute onset of these symptoms in a client taking haloperidol.
A) Agranulocytosis is a potential side effect of antipsychotic medications but does not present with the same symptoms as NMS.
B) Akathisia is characterized by restlessness and does not typically involve fever or muscle rigidity.
C) Tardive dyskinesia is a movement disorder that develops with long-term antipsychotic use and does not present acutely with fever and elevated blood pressure.
Therefore, the correct choice is D as it aligns with the client's presentation and medication history.
Question 4 of 5
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. The nurse should stay with the client to provide support and ensure safety. This action shows empathy and allows the nurse to assess the client's needs. Encouraging the client to go back to bed (
A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (
B) may not be appropriate without further assessment. Exploring alternatives to pacing (
D) is a good idea but should come after ensuring immediate support.
Question 5 of 5
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
Correct Answer: A
Rationale: The correct answer is A. This statement indicates understanding of the exposure therapy approach for agoraphobia, where the client gradually exposes themselves to feared situations. Sitting on a park bench signifies a step towards facing open spaces.
Choice B involves group therapy, which may not directly address agoraphobia.
Choice C with a book club does not specifically target agoraphobia.
Choice D suggests avoidance, which can reinforce fear.