ATI RN Mental Health 2023 Exam 3 | Nurselytic

Correct Answer: B

Rationale: The correct answer is B: Evaluate progress toward predetermined goals. During the working phase of a therapeutic relationship, the nurse assesses the client's progress towards the goals set during the initial phase. This step is crucial in determining the effectiveness of the interventions and making adjustments as needed. Informing the client about confidentiality rights (choice
A) is important in the orientation phase. Establishing boundaries (choice
C) is relevant in the introductory phase. Setting short- and long-term objectives (choice
D) is typically done in the initial phase.

Correct Answer: A

Rationale: The correct answer is A because the client's statement indicates a conflict between their spiritual practice (daily meditation time) and their therapy schedule, leading to potential spiritual distress. This conflict may disrupt the client's spiritual well-being.
B is incorrect as the increased visits from the spiritual advisor suggest support rather than distress. C indicates the client finds comfort in meditation, not distress. D shows that the client's faith provides hope, which is a positive aspect of their spiritual beliefs.

Correct Answer: D

Rationale: The correct answer is D: Offer hydration and nutrition to the client every 2 hours. This is essential to ensure the client's basic physiological needs are met while in restraints. Hydration and nutrition are vital for the client's well-being and overall health. Offering these every 2 hours helps prevent dehydration and malnutrition. Checking on the client every 30 minutes (Option
A) is important, but providing hydration and nutrition takes precedence. Assessing the client's need for toileting every 15 minutes (Option
B) may not be necessary unless there are specific concerns. Asking the provider to renew the prescription every 8 hours (Option
C) is not directly related to the client's immediate care needs.

Correct Answer: B

Rationale: The correct answer is B. Sitting with a client who has anorexia during mealtimes can be delegated to assistive personnel as it involves providing emotional support and encouragement. This task does not require specialized nursing skills and can be safely performed by assistive personnel under the supervision of a nurse.

Choices A, C, and D involve complex assessments, critical thinking, and specialized skills that should be performed by a licensed nurse. Reinforcing coping mechanisms, discussing relapse prevention, and administering medications all require nursing judgment and expertise. Delegating these tasks to assistive personnel could compromise the quality of care and put the client's safety at risk.

Correct Answer: C

Rationale: The correct answer is C: Ask the client if the medication is causing adverse effects. This is the most appropriate action to improve medication adherence because it addresses a potential barrier to taking the medication regularly. By inquiring about adverse effects, the nurse can assess if the client is experiencing any side effects that may be impacting their ability or willingness to take the medication. By identifying and addressing these issues, the nurse can work with the client to find solutions or alternatives to improve adherence.

Other choices are incorrect:
A: Threatening admission to an inpatient care facility is coercive and not a respectful or effective approach to improving adherence.
B: Discussing provider goals may not directly address the client's challenges with medication adherence.
D: Requesting a second medication without addressing the underlying issues may not solve the problem and can lead to further complications.