ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 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 first?
Correct Answer: A
Rationale: The correct answer is A: Ask the client what they are hearing. This is the first action the nurse should take to assess the nature and content of the auditory hallucinations. Understanding the hallucinations will help the nurse determine the level of distress the client is experiencing and develop an appropriate care plan.
Choice B: Focusing on reality-based topics may be helpful but should come after assessing the hallucinations to establish rapport and trust with the client.
Choice C: Taking the client for a walk outside may not address the immediate concern of the auditory hallucinations and may not be appropriate without first understanding the hallucinations.
Choice D: Encouraging the client to listen to music may not be helpful if the auditory hallucinations are distressing and could potentially exacerbate the symptoms.
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 attributing their blackouts to a seemingly logical and acceptable cause (low blood sugar) rather than acknowledging the true underlying issue of dissociative identity disorder. Rationalization involves creating logical explanations or justifications for behaviors, thoughts, or feelings that are otherwise unacceptable. In this case, the client is using rationalization to avoid facing the uncomfortable reality of their dissociative symptoms.
Incorrect choices:
A: Suppression involves consciously avoiding or pushing away thoughts or feelings. This does not apply to the client's situation.
B: Sublimation involves channeling unacceptable impulses into more socially acceptable behaviors. This is not demonstrated in the client's statement.
C: Projection involves attributing one's own thoughts or feelings to others. This is not evident in the client's statement.
Therefore, rationalization is the most appropriate defense mechanism being used by the client in this scenario.
Question 3 of 5
A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale:
1. Lithium can cause adverse effects like lethargy, muscle weakness, and blurred vision.
2. Regular blood tests are necessary to monitor lithium levels and potential toxicity.
3. Drawing blood helps determine if the client's symptoms are related to lithium toxicity.
4. Prompt intervention is crucial to prevent serious complications.
Summary:
A: Incorrect - Symptoms may indicate toxicity and require immediate attention.
C: Incorrect - Decreasing sodium intake is not directly related to the symptoms described.
D: Incorrect - Continuing the medication without addressing symptoms can lead to worsening toxicity.
Overall, choice B is the most appropriate as it addresses the need for blood monitoring to assess and manage potential lithium toxicity.
Question 4 of 5
A nurse is caring for a client who has a substance use disorder. The client states, 'The state took my child away after my overdose. I don’t want to go on living without them.' Which of the following therapeutic responses should the nurse make?
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.
Question 5 of 5
A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?
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.