ATI RN Mental Health 2023 Exam 2 | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: "Have you thought about harming yourself?" This response demonstrates active listening and shows concern for the client's safety, which is a priority when assessing suicidal ideation. Asking directly about self-harm can open up a dialogue for further assessment and intervention. It also allows the nurse to gauge the client's risk level and provide appropriate support or referrals.


Choice A is incorrect because it implies a conditional agreement that may not be achievable solely through counseling.
Choice B is inappropriate as prescribing sedatives without addressing the underlying issues is not therapeutic.
Choice D does not address the immediate safety concern and may not be feasible or safe.

Correct Answer: A,B

Rationale:
Correct
Answer: A, B


Rationale:
A: Identifying the client's stressors is important to understand the underlying cause of the behavior and helps in addressing the root issue.
B: Talking to the client using short, simple sentences can help in de-escalating the situation and ensuring effective communication.
C: Speaking to the client in a loud voice may escalate the situation further by increasing agitation and aggression.
D: Requesting security guards to restrain the client should be a last resort and may lead to physical harm and trauma.
E: Standing directly in front of the client can be perceived as confrontational and may escalate the situation further.

Correct Answer: D

Rationale:
Correct
Answer: D - Can you tell me more about what is upsetting you?


Rationale: This response demonstrates active listening and empathy. By encouraging the client to express their feelings, the nurse can better understand the underlying issues causing dissatisfaction. It shows willingness to address concerns and provide emotional support.

Incorrect

Choices:
A: Asking about family is not directly addressing the client's expressed concern about nursing care.
B: Anticipatory grieving is not the main issue here, so this response may dismiss the client's feelings.
C: Assuming the nurses are doing a good job without addressing the client's specific concerns may invalidate their feelings.
E, F, G: No information provided, but they are likely incorrect as they do not directly address the client's expressed dissatisfaction.

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.

Correct Answer: A

Rationale: The correct answer is A: Identify the client's current stage of grief. This is the priority because understanding the client's current stage of grief allows the nurse to tailor interventions accordingly. By assessing the client's stage, the nurse can provide targeted support and interventions to help the client process and cope with their grief effectively.


Choice B is incorrect because while informing the client about expected feelings is important, it is not the priority over assessing the current stage of grief.
Choice C is incorrect as physical activities may not be suitable or helpful depending on the client's stage of grief.
Choice D is also incorrect as discussing the use of a spiritual grief counselor should come after assessing the client's current needs and preferences.