ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, 'I think my blackouts are actually caused by low blood sugar.' The nurse should recognize the client is using which of the following defense mechanisms?
Correct Answer: D
Rationale: The correct answer is D: Rationalization. The client is using rationalization by attributing their blackouts to low blood sugar instead of acknowledging the possibility of dissociative identity disorder. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical explanations to avoid facing uncomfortable truths. In this scenario, the client is rationalizing their blackouts as a result of low blood sugar, which is a more socially acceptable reason compared to accepting the diagnosis of dissociative identity disorder.
Suppression (
A) involves consciously pushing unwanted thoughts or feelings out of awareness. Sublimation (
B) is redirecting unacceptable impulses into socially acceptable activities. Projection (
C) is attributing one's own thoughts or feelings onto others. In this case, the client is not using these defense mechanisms.
Question 2 of 5
A nurse is caring for a client who has a substance use disorder. The client states, 'The state took my child away after my overdose. I don’t want to go on living without them.' Which of the following therapeutic responses should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "Have you thought about harming yourself?" This response demonstrates active listening and shows concern for the client's safety, which is a priority when assessing suicidal ideation. Asking directly about self-harm can open up a dialogue for further assessment and intervention. It also allows the nurse to gauge the client's risk level and provide appropriate support or referrals.
Choice A is incorrect because it implies a conditional agreement that may not be achievable solely through counseling.
Choice B is inappropriate as prescribing sedatives without addressing the underlying issues is not therapeutic.
Choice D does not address the immediate safety concern and may not be feasible or safe.
Question 3 of 5
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B
Rationale:
Correct
Answer: A, B
Rationale:
A: Identifying the client's stressors is important to understand the underlying cause of the behavior and helps in addressing the root issue.
B: Talking to the client using short, simple sentences can help in de-escalating the situation and ensuring effective communication.
C: Speaking to the client in a loud voice may escalate the situation further by increasing agitation and aggression.
D: Requesting security guards to restrain the client should be a last resort and may lead to physical harm and trauma.
E: Standing directly in front of the client can be perceived as confrontational and may escalate the situation further.
Question 4 of 5
A nurse is caring for a client who is receiving end-of-life care. The client states, 'The nurses here don’t do a good job caring for me.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale:
Correct
Answer: D - Can you tell me more about what is upsetting you?
Rationale: This response demonstrates active listening and empathy. By encouraging the client to express their feelings, the nurse can better understand the underlying issues causing dissatisfaction. It shows willingness to address concerns and provide emotional support.
Incorrect
Choices:
A: Asking about family is not directly addressing the client's expressed concern about nursing care.
B: Anticipatory grieving is not the main issue here, so this response may dismiss the client's feelings.
C: Assuming the nurses are doing a good job without addressing the client's specific concerns may invalidate their feelings.
E, F, G: No information provided, but they are likely incorrect as they do not directly address the client's expressed dissatisfaction.
Question 5 of 5
A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will place a sliding bolt lock just above the doorknob." This statement indicates an understanding of the teaching on home safety for a client with advanced Alzheimer's disease because it addresses the specific safety measure of installing a sliding bolt lock to prevent the client from wandering outside unsupervised. This type of lock is a practical strategy to enhance the client's safety by restricting access to potentially dangerous areas.
Choice A is incorrect because notifying law enforcement within 2 hours of the client not being found is not a preventative safety measure.
Choice B is incorrect as giving a photo to the police is reactive and may not prevent the client from wandering.
Choice D is incorrect as ensuring the bedroom is dark at night does not directly address the safety concern of wandering.