ATI RN
ATI Mental Health Quiz Questions
Extract:
Question 1 of 4
A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.)
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E because they are indicative of the preassaultive stage of violence. Defensive responses (
A) suggest the client is becoming defensive and may escalate to violence. Agitation (
D) signifies increasing tension and potential aggression. Facial grimacing (E) can be a nonverbal sign of anger or frustration. Lethargy (
B) and disorientation (
C) are not typically associated with the preassaultive stage, as they indicate a lack of energy or confusion rather than impending violence.
Therefore, choices B and C are incorrect in this context.
Question 2 of 4
The admitting nurse asks a client, 'Hi John, what would you like to talk about in group today?' The client replies, 'Hi john, what would you like to talk about in group today.' The nurse should recognize this response as an example of which of the following?
Correct Answer: A
Rationale: The correct answer is A: Echolalia. Echolalia is the repetition of words or phrases spoken by others. In this case, the client's response mirrors exactly what the nurse said, indicating a repetitive behavior. The other choices are incorrect because: B: Word salad is a jumble of unrelated words or phrases, which is not demonstrated in the client's response. C: Flight of ideas refers to a rapid, continuous flow of speech with abrupt changes in topic, which is not evident here. D: Clanging involves stringing together words based on sound, not meaning, which is not present in the client's response.
Question 3 of 4
A nurse is caring for client who spent the past several minutes mumbling about being doomed to die and is now pacing in an increasingly agitated and angry manner. Which of the following actions is should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Attempt to reduce environmental stimuli. This is the appropriate action because the client is exhibiting signs of agitation and distress. By reducing environmental stimuli, such as noise and visual distractions, the nurse can help calm the client and prevent escalation of the situation. Administering medication, using physical restraints, or placing the client in seclusion should only be considered as a last resort when all other interventions have failed. These options can further agitate the client and compromise their autonomy. It is important for the nurse to prioritize non-pharmacological interventions and maintain a therapeutic environment to support the client's emotional well-being.
Question 4 of 4
A nurse in an acute care mental health facility is caring for a client who has paranoid schizophrenia and suddenly becomes angry and uncontrollably violent toward staff. Which of the following medications should the nurse expect the provider to prescribe?
Correct Answer: B
Rationale: The correct answer is B: Haloperidol. Haloperidol is a typical antipsychotic medication commonly used to manage acute episodes of aggression and agitation in clients with schizophrenia. It helps to reduce psychotic symptoms and aggressive behaviors by blocking dopamine receptors in the brain. Paroxetine hydrochloride (
A) is an SSRI used for depression and anxiety, not acute aggression. Lithium carbonate (
C) is a mood stabilizer primarily used for bipolar disorder. Propranolol (
D) is a beta-blocker used for anxiety and high blood pressure, not for managing acute aggression in schizophrenia.
Extract:
Nurses' Notes
1000:
Client became upset in activity room because they lost a card game.
Client yelled at other clients stating. "They always cheat me!”
Client walks to their room and sits on bed.
1015:
Client returns to activity room; posture tense, fists clenched, and yells and uses obscenities toward staff members and other clients.
Asked client to calm down, explained consequences of their inappropriate behavior, and to share what took place. Maintained safe distance and asked client to have seat to talk about their anger.
Client's behavior continues to escalate.
Question 5 of 4
Client's behavior continues to escalate. A nurse is caring for a client in an inpatient psychiatry unit, Drag words from the choices below to fill in each blank in the following sentence ,Which of the following actions should the nurse take first? The nurse should ___ followed by ___.
Correct Answer: C,D
Rationale: Action to Take: Offer the client a physical outlet, Offer the client medication; Potential Condition: Escalating behavior; Parameter to Monitor: Client's behavior, Client's response to offered outlets.
Rationale: When a client's behavior continues to escalate in an inpatient psychiatry unit, the nurse's first action should be to offer the client a physical outlet as a non-restrictive and non-confrontational approach to de-escalate the situation. This allows the client to release built-up tension and energy in a safe manner. Additionally, offering medication can help address any underlying anxiety or agitation contributing to the escalation. By monitoring the client's behavior and response to the offered outlets, the nurse can assess the effectiveness of the interventions and make further adjustments as needed. Placing the client in restraints should be avoided as it can escalate the situation further, and grabbing the client's hand may be perceived as confrontational or threatening, potentially worsening the behavior.