ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Vital Signs
Blood pressure: 112/68 mm Hg
Temperature: 37° C (98.6° F)
Heart rate: 64/min
Respiratory rate: 12/min
Oxygen saturation: 98% on room air
Medical History
A 19-year-old female client presents to the clinic accompanied by her parents. The parents indicate they "have to do something or she is going to end up in jail - we cannot believe a thing she tells us.” The client is disinterested, standing with arms crossed, and not answering questions when addressed. Her parents indicate she “can be very nice to be around, but when denied something she wants, she becomes aggressive and abusive.” Parents report impulsivity and that the client does not show remorse for her actions. According to her parents, “she is reckless and irresponsible.” The parents indicate this type of behavior started around age 13 and has recently become more frequent. The client states, “I can do what I want. Nobody is going to tell me what to do.”
Question 1 of 5
A nurse is caring for a client. Exhibits:Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Correct Answer: B, A&E, C&E
Rationale: The correct answer is B, A&E, C&E. The client is most likely experiencing a personality disorder, which falls under the category of mental health conditions. The nurse should address this by first assessing the specific personality disorder the client may have (choice
A) to tailor the care plan accordingly. Next, the nurse should maintain a low-stimuli environment and establish clear boundaries (choices
A) to help manage the client's behaviors and promote a sense of safety. The nurse should monitor daily weight and proactive behavior (choice
C) to assess physical and psychological well-being, and monitor aggressive and violent behavior and deceitfulness (choice E) to evaluate progress and potential risks. The other choices are incorrect as they do not address the specific mental health condition or appropriate actions and parameters for managing and assessing the client's condition effectively.
Extract:
Question 2 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 3 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.
Question 4 of 5
A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Initiate fall precautions for the client. Lorazepam is a benzodiazepine that can cause sedation and drowsiness, increasing the risk of falls. Fall precautions should be implemented to ensure the client's safety.
Choice A is incorrect because repeating the dose can lead to overdose.
Choice C is incorrect as lorazepam does not typically cause ringing in the ears.
Choice D is inappropriate and unethical unless absolutely necessary for the client's safety, which is not indicated in this scenario.
Question 5 of 5
A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?
Correct Answer: B
Rationale: The correct answer is B: A translator of the same gender as the client. This choice ensures effective communication while also considering the cultural and gender preferences of the client. The translator will facilitate accurate exchange of information, maintaining confidentiality.
Choice A, a unit secretary, may not have the necessary skills for translation.
Choice C, another client, may not be reliable or appropriate to maintain professional boundaries.
Choice D, a family member, may introduce bias or confidentiality concerns.