ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is in physical restraints. Which of the following actions by the client indicates the restraints can be discontinued?
Correct Answer: B
Rationale: If the client demonstrates control over their actions, it suggests they are no longer at immediate risk of harm, allowing consideration for discontinuing restraints. This aligns with guidelines to use restraints only when necessary and remove them as soon as safe. An apology, a request for release, or a contract are positive but insufficient without evidence of sustained behavioral control.
Question 2 of 5
A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, 'I can't think about that until after my first grandchild is born next week.' The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?
Correct Answer: A
Rationale: Suppression involves consciously avoiding distressing thoughts, as seen here, but delaying a terminal diagnosis indefinitely can be maladaptive, hindering treatment. Compensation, regression, and sublimation involve different mechanisms (overachieving, reverting, or redirecting impulses), not applicable here.
Question 3 of 5
A nurse in an acute care facility is planning care for a client with a history of alcohol use disorder who is admitted while intoxicated. Which of the following interventions should the nurse implement?
Correct Answer: A
Rationale: Implementing seizure precautions is critical for a client with alcohol use disorder admitted while intoxicated. Alcohol withdrawal can lead to seizures, a life-threatening risk, requiring a safe environment and emergency readiness. Orthostatic hypotension monitoring is useful but secondary; methadone is for opioid withdrawal, not alcohol; and acidifying urine is irrelevant to alcohol management.
Question 4 of 5
A nurse is planning care for a client who has borderline personality disorder. Which of the following interventions should the nurse plan to include to assist the client with impaired social interactions with others?
Correct Answer: D
Rationale: Assigning the same staff daily provides stability and trust, aiding social interaction for a client with borderline personality disorder. Avoiding maladaptive behaviors hinders therapy, exploring abandonment is relevant but indirect, and encouraging dependency is counterproductive.
Question 5 of 5
A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Offering hydration and nutrition every 2 hours is critical to meet the client’s basic needs and prevent dehydration or malnutrition, aligning with restraint care guidelines. Checking every 30 minutes is insufficient (15-minute checks are standard); toileting every 15 minutes is excessive; and renewal every 8 hours doesn’t match typical 24-hour protocols.