ATI RN
ATI Custom NSG 133 Mental Health Final Exam Summer (2023) Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take to demonstrate a therapeutic approach?
Correct Answer: C
Rationale: The correct answer is C: Set consistent limits on the client’s manipulative behavior. This is the most appropriate action when caring for a client with borderline personality disorder because it helps establish clear boundaries and structure, which are crucial in managing their manipulative tendencies. Setting consistent limits also fosters a sense of safety and predictability for the client, promoting a therapeutic environment.
Allowing the client unlimited time to make decisions (
A) may lead to indecisiveness and reinforce maladaptive behaviors. Identifying with the client’s feelings of emptiness (
B) may blur professional boundaries and hinder the therapeutic relationship. Encouraging the client to attend daily group therapy sessions (
D) is beneficial, but setting limits on manipulative behavior takes precedence in this scenario.
Question 2 of 5
A nurse is caring for a client who is experiencing delirium tremens. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A. Administer thiamine as prescribed.
Rationale: Thiamine is essential in treating delirium tremens, as it helps prevent Wernicke's encephalopathy, a severe complication associated with alcohol withdrawal. Thiamine supplementation is crucial to prevent neurological damage. Other choices are incorrect because placing the client in a dark room may worsen confusion, encouraging ambulation can be dangerous due to impaired cognition and coordination, and providing caffeinated beverages can exacerbate symptoms by increasing agitation and anxiety.
Question 3 of 5
A nurse is caring for a client who has a history of aggressive behavior. Which of the following actions should the nurse take to de-escalate the client’s behavior?
Correct Answer: D
Rationale: The correct answer is D: Remain calm and speak in a soothing tone. This approach is effective in de-escalating aggressive behavior as it helps to convey a sense of calm and safety to the client. Speaking in a soothing tone can help reduce the client's anxiety and aggression. It also shows empathy and understanding towards the client, which can help build rapport and trust. This approach allows the nurse to maintain control of the situation without escalating it further.
Choices A, B, and C are incorrect because speaking loudly, maintaining constant eye contact, and standing too close to an agitated client can all be perceived as confrontational and may escalate the situation further. These actions can increase the client's agitation and potentially lead to a more aggressive response. It is important to maintain a non-threatening and calming demeanor when dealing with aggressive behavior to ensure the safety of both the client and the nurse.
Question 4 of 5
A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Ask the client what the voices are saying. This action allows the nurse to gather information about the content and context of the hallucinations, which can help in understanding the client's experiences and developing an appropriate care plan. Encouraging the client to argue with the voices (
B) may lead to increased distress and is not a recommended therapeutic approach. Telling the client that the voices are not real (
C) may invalidate their experiences and damage the therapeutic relationship. Instructing the client to ignore the voices completely (
D) may be challenging and unrealistic.
Question 5 of 5
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Provide a quiet environment with minimal stimulation. In the manic phase of bipolar disorder, individuals may experience heightened energy levels, irritability, and decreased need for sleep. Providing a quiet environment with minimal stimulation can help reduce agitation and hyperactivity. This intervention promotes a calming atmosphere, which can aid in managing the client's symptoms and preventing potential escalation of manic behavior. Encouraging detailed planning activities (
Choice
A) may exacerbate the client's racing thoughts and impulsivity. Instructing the client to write about their feelings (
Choice
C) may not be effective in managing the intense energy associated with mania. Offering complex tasks to complete (
Choice
D) can overwhelm the client and may increase stress levels.