ATI RN
ATI RN Mental Health 2023 III Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Offer the client the medication at the next scheduled dose time. This option respects the client's autonomy and right to refuse treatment, while also ensuring that the client receives the necessary medication. By offering the medication at the next scheduled time, the nurse can continue to monitor the client's condition and provide support without resorting to coercive measures.
Option B: Implement consequences until the client takes the medication, is incorrect as it goes against the client's right to refuse treatment and may damage the therapeutic relationship.
Option C: Inform the client that he does not have the right to refuse the medication, is incorrect as it disregards the client's autonomy and can lead to further resistance to treatment.
Option D: Administer the medication to the client via IM injection, is incorrect as it violates the client's right to make informed decisions about their treatment. This approach should only be considered in emergency situations where the client's safety is at risk.
Question 2 of 5
A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: "It must be difficult for you to feel this way after losing your partner." This response validates the partner's feelings without dismissing or minimizing them. It acknowledges the partner's struggle with guilt and offers empathy and understanding. It recognizes the complexity of grief and allows the partner to express their emotions.
Incorrect responses:
A: This response jumps to a solution without acknowledging the partner's emotions first.
B: This response shifts the focus to the nurse's personal experience, which may not be relevant or helpful to the partner.
D: This response dismisses the partner's feelings and may come across as invalidating.
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: A
Rationale: Rationale for
Choice A (Correct Answer): The nurse should advise the client to have their blood drawn because the symptoms of lethargy, muscle weakness, and blurred vision could indicate lithium toxicity. Regular monitoring of lithium levels through blood tests is crucial to prevent toxicity and ensure the client's safety.
Summary of Other
Choices:
B: These symptoms will not necessarily improve over time as they could be indicative of lithium toxicity.
C: Decreasing sodium intake is not directly related to managing lithium toxicity symptoms.
D: Continuing the medication without addressing the symptoms of toxicity can lead to further complications.
E, F, G: No information provided for these choices.
Question 4 of 5
A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Monitor the child's vital signs every 15 minutes. This action is essential to ensure the child's safety while in restraints. Monitoring vital signs helps the nurse assess the child's physiological response to the restraints, such as changes in heart rate, blood pressure, and respiratory rate. This allows for early detection of any complications or distress, enabling prompt intervention if necessary. It is crucial to closely monitor vital signs in this situation to prevent any adverse outcomes related to the use of physical restraints. Keeping the restraints on for a minimum of 1 hour (
A) is not appropriate as the duration should be based on the child's behavior and safety. Asking the provider to renew the prescription for the restraints every 24 hours (
C) is important but not the immediate priority. Arranging an in-person evaluation by the child's provider within 2 hours of initiating restraints (
D) is also important, but monitoring vital signs is the more immediate and critical action
Question 5 of 5
A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?
Correct Answer: A
Rationale: The correct answer is A: Participate in solitary activities with a client who has mania. Assistive personnel can engage in activities that provide social interaction and support for clients with mania. This task does not require specialized nursing knowledge or assessment skills. The other choices involve providing education, obtaining consent, or explaining treatment modalities, which should be done by a licensed nurse due to the complexity and potential risks involved. It is important to delegate tasks that align with the assistive personnel's scope of practice and level of training to ensure safe and effective client care.