ATI RN Mental Health 2023 with NGN | Nurselytic

Correct Answer: C

Rationale:
Rationale:
Choice C is the correct answer because it demonstrates active listening and shows concern for the client's well-being. By asking if the client has thought about harming themselves, the nurse assesses suicide risk and can intervene appropriately. This response opens up a dialogue for further exploration of the client's emotional state and provides an opportunity for crisis intervention if needed.

Summary:
A: Incorrect. Making promises about regaining custody can give false hope and is not therapeutic.
B: Incorrect. Prescribing sedatives does not address the underlying emotional distress and may mask the client's feelings.
D: Incorrect. Involving family members in custody issues may not be appropriate and does not address the client's emotional needs.
E, F, G: Not applicable.

Correct Answer: C

Rationale: The correct answer is C: Ask the client if he intends to harm others. This is the priority action because it directly addresses the safety of the other clients. By assessing the client's intentions, the nurse can determine the level of risk and take appropriate measures to prevent harm.


Choice A is incorrect because exploring stress reduction techniques is not the immediate priority when there is a risk of harm to others.


Choice B is incorrect as role modeling healthy ways to express anger is not as urgent as addressing the current aggressive behavior.


Choice D is incorrect as making a list of things that make the client angry does not address the immediate safety concerns of the other clients.

Overall, the priority in this situation is to assess the client's intentions to prevent harm to others.

Correct Answer: C

Rationale: The correct answer is C: Implement measures to prevent intentional self-inflicted injury. This is the priority because individuals with borderline personality disorder are at high risk for self-harm behaviors. Preventing harm to the client is the most immediate concern to ensure their safety and well-being. Encouraging support group attendance (
A) and discussing assertive behavior (
B) are important but not as critical as preventing self-injury. Assisting the client to maintain awareness of thoughts and feelings (
D) is also important but not the priority in this case.

Correct Answer: B

Rationale: The correct answer is B: Establish confidentiality guidelines with the client. This is the first step in building a trustful nurse-client relationship, especially in mental health settings where privacy is crucial. By setting clear confidentiality guidelines, the nurse ensures the client's information is kept confidential, fostering a sense of safety and trust. This initial step lays the foundation for open communication and collaboration between the nurse and the client.


Choice A is incorrect because assisting the client with coping strategies comes after establishing trust and confidentiality.
Choice C is incorrect as helping the client make behavioral changes is a later stage in the therapeutic process.
Choice D is incorrect because sharing information about the disorder should come after the trust has been established and confidentiality guidelines have been discussed.

Correct Answer: A,B

Rationale:
Correct
Answer: A, B


Rationale:
A: Identifying the client's stressors helps address the root cause of the behavior and provides insight into how to support the client effectively.
B: Talking to the client using short, simple sentences can help de-escalate the situation by promoting clear communication and reducing confusion.

Incorrect

Choices:
C: Speaking to the client in a loud voice can escalate the situation further, increasing agitation and distress.
D: Requesting security guards to restrain the client should be a last resort as it can lead to physical harm and worsen the client's emotional state.
E: Standing directly in front of the client can be perceived as confrontational and may increase the client's feelings of being trapped or threatened.