ATI RN
ATI Mental Health Assessment I Questions
Extract:
Question 1 of 5
A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Bradypnea. Bradypnea, or slow breathing, is a serious side effect of hydromorphone, indicating potential respiratory depression which can be life-threatening. This finding should be reported immediately to the provider for prompt intervention to prevent respiratory failure.
A: Urinary retention is a common side effect of diazepam but not typically urgent.
B: Blurred vision is a common side effect of diazepam but is not as urgent as potential respiratory depression.
C: Headache is not typically a priority finding compared to potential respiratory depression.
Overall, the priority is to address the potentially life-threatening side effect of bradypnea in a client taking hydromorphone.
Question 2 of 5
A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?
Correct Answer: A
Rationale: The correct answer is A: A nurse did not clarify a client's prescription that was difficult to read resulting in a medication error. This scenario represents an unintentional tort known as negligence. Negligence occurs when a healthcare provider fails to adhere to the standard of care, resulting in harm to the patient. In this case, the nurse's failure to clarify the prescription demonstrates a lack of due diligence, which led to a medication error. This is considered unintentional because the nurse did not intentionally harm the client but acted carelessly.
Summary of other choices:
B: Posting private information violates patient confidentiality, which is an intentional tort.
C: Placing a client in restraints without a prescription is a violation of the client's rights and can lead to physical harm, making it an intentional tort.
D: Threatening a client with physical harm is an intentional act and constitutes assault, an intentional tort.
Question 3 of 5
A nurse is caring for a client who has bipolar disorder. The client says to the nurse, 'Give me your pen to cut the pain out of my chest.' The nurse should identify that the client is at risk for which of the following?
Correct Answer: D
Rationale: The correct answer is D: Self-mutilation. The client's statement indicates a desire to physically harm themselves, a common behavior in individuals with bipolar disorder during manic or depressive episodes. Self-mutilation is a serious concern that requires immediate intervention to prevent harm.
A: Illusion is incorrect as it refers to a misinterpretation of stimuli, not self-harm.
B: Hallucination is incorrect as it involves perceiving things that are not present, not self-harm.
C: Attention-seeking behavior is incorrect as the client's statement indicates distress rather than seeking attention.
Question 4 of 5
A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?
Correct Answer: D
Rationale: The correct answer is D because it demonstrates active listening and empathy by acknowledging the client's concerns and offering to discuss solutions collaboratively.
Choice A is incorrect as it suggests a potentially harmful solution.
Choice B dismisses the client's feelings.
Choice C assumes the client has a family member available. Overall, choice D promotes a therapeutic nurse-client relationship by addressing the client's needs and involving them in the decision-making process.
Question 5 of 5
A nurse is providing teaching to the caretakers of a client who has Alzheimer's disease with mild cognitive decline. The client is beginning to experience sleep disturbances. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale:
Correct
Answer: B - Wake the client at the same time each morning.
Rationale: Maintaining a consistent wake-up time helps regulate the client's circadian rhythm, promoting a regular sleep-wake cycle. This approach can improve overall sleep quality and reduce sleep disturbances commonly seen in Alzheimer's patients with mild cognitive decline.
Incorrect
Choices:
A: Giving the client a cup of hot black tea before bed may introduce caffeine, which can disrupt sleep patterns.
C: Taking the client for a walk close to bedtime may increase stimulation, making it harder for the client to fall asleep.
D: Allowing the client to take a 90-minute nap after lunch could lead to difficulty falling asleep at night due to increased daytime sleepiness.