ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.
Question 2 of 5
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
Correct Answer: C
Rationale: Identifying warning signs in client behavior helps prevent future suicides and improves staff awareness.
Question 3 of 5
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?
Correct Answer: A
Rationale:
Correct Answer: A. The client can be kept in the hospital after the 72-hour hold is over if they are a danger to themselves or others. This is based on the principle of duty to warn and protect, ensuring the safety of the client and others. This decision is made to prevent harm and provide necessary treatment.
B: This choice is incorrect because unwillingness to accept treatment does not necessarily indicate immediate danger to self or others, which is the primary concern in this scenario.
C: Liking or disliking a neighbor is not a sufficient reason to keep a client in the hospital after the 72-hour hold. It does not address the immediate safety concerns.
D: Planning to move out of state does not indicate imminent danger to self or others, which is the primary factor in determining the need for continued hospitalization.
In summary, choice A is correct because it addresses the immediate safety risk, while the other choices do not directly relate to the client's current threat level.
Question 4 of 5
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?
Correct Answer: D
Rationale: Safety is the priority for clients experiencing manic episodes, as they are at risk for self-harm.
Question 5 of 5
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, 'I don't know what I will do if they find I have cancer.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct response is D: "I'm hearing that you are concerned that it might turn out that you have cancer." This answer demonstrates active listening, empathy, and acknowledgment of the client's feelings without dismissing or invalidating them. By paraphrasing the client's concerns, the nurse shows understanding and provides an opportunity for the client to express their fears further.
Choice A is incorrect because it challenges the client's perception rather than validating their feelings.
Choice B is dismissive and does not address the client's emotional needs.
Choice C shifts the responsibility to the provider and misses the opportunity for the nurse to offer support.
In summary, choice D is the most appropriate response as it acknowledges the client's emotions, fosters open communication, and demonstrates empathy, which are essential in providing holistic care.