ATI RN
ATI RN Mental Health 2019 NGN Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect?
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
A: Bradycardia is common in anorexia nervosa due to malnutrition.
B: Russell's sign, calluses on knuckles from induced vomiting, is seen in bulimia but can occur in anorexia nervosa with purging behaviors.
C: Lanugo, fine hair growth on the body, is a sign of malnutrition in anorexia nervosa.
D: Hypotension can occur due to dehydration and malnutrition.
Incorrect answers:
E: Diarrhea is not typically associated with anorexia nervosa; constipation is more common.
Question 2 of 5
A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Reassure staff members that the debriefing is confidential. This intervention should be taken first because it creates a safe and trusting environment for staff to openly express their feelings and experiences without fear of judgment or repercussions. Confidentiality helps build psychological safety, which is crucial for effective debriefing. Asking staff to describe traumatic memories (
A) could trigger distress without proper support. Having staff discuss their involvement (
B) might be overwhelming without first ensuring confidentiality. Providing stress-management exercises (
D) is important but should come after establishing trust and safety.
Question 3 of 5
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Sore throat. This is the priority finding to report because it could indicate a potential serious side effect of clozapine called agranulocytosis, which is characterized by a low white blood cell count and can lead to severe infections. Agranulocytosis is a life-threatening condition that requires immediate medical attention. Reporting this finding promptly allows for early intervention to prevent complications.
Other choices are less urgent: A: Random blood glucose 130 mg/dL is slightly elevated but not immediately concerning. B: Heart rate 104/min may be within normal range depending on the individual. C: Nausea is a common side effect of clozapine but not as critical as a sore throat.
Question 4 of 5
A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
Correct Answer: A
Rationale: The correct answer is A: Demonstrate how to verbally de-escalate the situation. The nurse manager should first attempt to verbally de-escalate the situation to ensure the safety of the client and staff. This approach prioritizes communication and attempts to address the client's concerns and reasons for refusal before considering other interventions. Assessing the need for physical restraints (
B) should only be considered as a last resort for safety concerns. Stopping the newly licensed nurse from administering the medication (
C) may not address the underlying issue of the client's refusal. Discussing the purpose of the medication with the client (
D) may be important but should come after attempting to de-escalate the situation.
Question 5 of 5
A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?
Correct Answer: D
Rationale: The correct answer is D: Establish a rapport with group members. During the orientation phase of a support group, it is crucial for the nurse to build a trusting relationship with group members. This helps create a safe and welcoming environment for participants to share their thoughts and feelings. By establishing rapport, the nurse sets the foundation for effective communication and encourages group members to engage in the support group activities.
Incorrect options:
A: Managing conflict within the group is more relevant during the working phase of the group, not the orientation phase.
B: Encouraging problem-solving skills is important, but establishing rapport comes first in building a supportive environment.
C: Maintaining the group's focus on identified issues is essential but is more relevant during the working phase once rapport is established.