ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?
Correct Answer: D
Rationale: The correct answer is D: Spending time sitting with the client. This approach promotes therapeutic communication and provides emotional support, showing the client they are not alone. It allows the nurse to actively listen, build rapport, and establish trust. Sitting with the client creates a safe space for them to express their feelings and concerns. Encouraging decision-making (
A) may be overwhelming for someone with severe depression. Playing a game of chess (
B) may not be suitable for someone who is not in the right mindset. Giving choices of activities (
C) may add unnecessary pressure.
Question 2 of 5
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
Correct Answer: C
Rationale: Rationale for
Choice C being correct: The statement "I will develop a decreased physical response to alcohol" indicates an understanding of alcohol tolerance, where the body requires more alcohol to achieve the same effects. This demonstrates comprehension of the concept.
Summary of why other choices are incorrect:
A: Incorrect. Alcohol tolerance does not produce physical changes when alcohol is not ingested.
B: Incorrect. Alcohol tolerance does not affect the response to opiates.
D: Incorrect. Alcohol tolerance is not a medical emergency and is not solely a result of withdrawal.
Question 3 of 5
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. This is the first action the nurse should take because delirium tremens is a severe form of alcohol withdrawal that can lead to life-threatening complications such as seizures and hallucinations. Diazepam is a benzodiazepine medication that helps to control the symptoms of alcohol withdrawal by calming the central nervous system. Administering diazepam promptly can prevent the client from experiencing severe symptoms and reduce the risk of complications.
Raising the side rails of the bed (
B) may be important for safety but is not the first priority in managing delirium tremens. Obtaining a medical history (
C) is important for overall assessment but is not the immediate action needed in this critical situation. Starting intravenous fluids (
D) may be necessary to maintain hydration but does not address the urgent need to manage the symptoms of delirium tremens.
Question 4 of 5
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
Question 5 of 5
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?
Correct Answer: C
Rationale: The correct answer is C: The client has lost 30 lb. This indicates maladaptive grieving as significant weight loss is a common physical manifestation of unresolved grief. The weight loss could be due to lack of appetite or neglecting self-care, both of which are concerning signs. Losing a large amount of weight within a short period can negatively impact the client's health and well-being.
Choices A, B, and D are not directly related to maladaptive grieving. Age (
A) and the time since the husband's death (
B) are not indicative of maladaptive grieving, as everyone grieves differently and at their own pace. Difficulty sleeping (
D) is a common symptom of grief but may not necessarily indicate maladaptive grieving on its own.