ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Focus the client on reality-based activities. This is because redirecting the client's focus to reality-based activities can help ground them and reduce the intensity of the hallucinations. Avoiding direct questions (
A) may not address the client's current distress. Conveying sympathy (
C) is important but may not directly address the hallucinations. Telling the client her experience is not real (
D) may invalidate their feelings and worsen the situation. It is crucial to engage the client in reality-based activities to help them cope effectively.
Question 2 of 5
A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Initiate fall precautions for the client. Lorazepam is a benzodiazepine that can cause sedation and drowsiness, increasing the risk of falls. Fall precautions should be implemented to ensure the client's safety.
Choice A is incorrect because repeating the dose can lead to overdose.
Choice C is incorrect as lorazepam does not typically cause ringing in the ears.
Choice D is inappropriate and unethical unless absolutely necessary for the client's safety, which is not indicated in this scenario.
Question 3 of 5
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
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.
Question 4 of 5
A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Maintain a low level of environmental stimuli. Command hallucinations in schizophrenia can be exacerbated by high levels of environmental stimuli. By minimizing distractions and maintaining a calm environment, the nurse can help reduce the likelihood of the client experiencing these hallucinations. This intervention supports the client's ability to focus and differentiate between reality and hallucinations.
Choice B: Avoid making eye contact when speaking with the client is incorrect because avoiding eye contact may isolate the client further and hinder therapeutic communication.
Choice C: Encourage increased socialization during group therapy is incorrect because group therapy may overwhelm the client and increase the risk of experiencing command hallucinations.
Choice D: Provide reassurance and comfort for the client through touch is incorrect because touch may not be appropriate for all clients and may not directly address the underlying issue of command hallucinations.
Question 5 of 5
A nurse is receiving a change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?
Correct Answer: B
Rationale: The correct answer is B: A client who has conversion disorder. Clients with conversion disorder may experience sensory impairments such as blindness or paralysis that cannot be explained by medical conditions. The nurse should assess for risks related to these impairments to ensure the client's safety.
Incorrect choices:
A: A client with narcissistic personality disorder does not typically present with sensory impairments.
C: A client with mild anxiety disorder may have heightened sensory perception but not necessarily sensory impairments.
D: A client with severe obsessive-compulsive disorder may have sensory sensitivities but not impairments like those seen in conversion disorder.