ATI RN
ATI NURS 4850 Mental Health Questions
Extract:
Question 1 of 5
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Sitting steadily without support. At around 6 months, infants typically achieve the milestone of sitting without support, demonstrating improved head control and trunk strength. This milestone indicates proper neuromuscular development. Closed posterior fontanel (
A) is expected in the first few months of life, not at 6 months. Lateral incisors (
B) typically erupt around 9-11 months. Using thumb and index fingers in a pincer grasp (
C) usually occurs around 9-10 months. Overall, the ability to sit steadily without support is the most appropriate developmental milestone for a 6-month-old infant.
Question 2 of 5
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
Correct Answer: C,D,E
Rationale: The correct answer for expected findings of OCD are C: Perfectionist behavior, D: Difficulty relaxing, and E: Rule conscious behavior. Perfectionist behavior is common in OCD due to the need for things to be perfect or done a certain way to alleviate anxiety. Difficulty relaxing is seen in individuals with OCD as they often feel compelled to engage in rituals or compulsions. Rule conscious behavior relates to the strict adherence to self-imposed rules or routines in an attempt to manage anxiety.
Incorrect choices:
A: Unaware of compulsions - Individuals with OCD are typically aware of their compulsions and the distress they cause.
B: Irrational fear of certain objects - This is more characteristic of specific phobias rather than OCD.
Question 3 of 5
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Muscle tremors. A calcium level of 8.0 mg/dL in a preschooler indicates hypocalcemia. Muscle tremors are a common manifestation of hypocalcemia due to the effect of low calcium levels on nerve and muscle function. Chvostek's sign is a facial muscle spasm elicited by tapping the facial nerve and is associated with hypocalcemia, so it should be positive, not negative. Polyuria is not typically associated with hypocalcemia. Dry, sticky mucous membranes are more indicative of dehydration rather than hypocalcemia. In summary, muscle tremors are the most likely finding due to the low calcium level in the preschooler.
Question 4 of 5
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client’s plan of care?
Correct Answer: D
Rationale: The correct answer is D: Spending time sitting with the client. This approach is therapeutic because it demonstrates empathy, provides emotional support, and creates a safe space for the client to express their feelings. It helps build a trusting nurse-client relationship, which is crucial in treating depression. Playing a game of chess (
A) may not address the client's emotional needs. Giving choices (
B) and encouraging decision-making (
C) may overwhelm a client with severe depression. Sitting with the client (
D) allows for non-verbal communication and connection.
Question 5 of 5
A nurse is caring for a client who has schizophrenia and tells the nurse,“They lie about me all the time and they are trying to poison my food.” Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without validating the delusions. It shows empathy and understanding without challenging the client's beliefs.
Choice A asks for specific details that may reinforce the delusions.
Choice C denies the client's reality, which can damage the therapeutic relationship.
Choice D encourages the client to explain their delusions, potentially reinforcing them.