ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice
A), diaphoresis (choice
B), and tremors (choice
C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations.
Therefore, addressing visual hallucinations takes priority over these symptoms.
Question 2 of 5
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
Correct Answer: C
Rationale: The correct answer is C: Major depressive disorder. Clients with major depressive disorder are at the highest risk for suicide due to the severity of their symptoms, including feelings of hopelessness, worthlessness, and suicidal ideation. This diagnosis is associated with a higher rate of completed suicides compared to other depressive disorders. Clients with premenstrual dysphoric disorder (
A) experience mood changes related to their menstrual cycle but do not typically have an increased risk of suicide. Seasonal affective disorder (
B) is characterized by seasonal changes in mood and energy levels but is not typically associated with a high risk of suicide. Persistent depressive disorder (
D) involves chronic depressive symptoms but does not necessarily indicate an increased risk of suicide.
Question 3 of 5
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.
Question 4 of 5
A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?
Correct Answer: D
Rationale: The correct answer is D: Safety plan. For a client with borderline personality disorder, a safety plan is crucial to prevent self-harm or suicidal behaviors. This intervention helps the client identify triggers, coping strategies, support resources, and steps to take in a crisis. A: Dialectical behavior therapy is a comprehensive treatment, not just a discharge plan. B: Behavioral contract may not address the immediate safety concerns. C: Milieu therapy focuses on the therapeutic environment, not individual discharge planning.
Question 5 of 5
A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statements should the nurse make?
Correct Answer: B
Rationale:
Correct
Answer: B
Rationale: Offering the client the option to hold the stillborn baby allows for the initiation of the grieving process and provides closure. It shows empathy and respect for the client's loss, allowing them to spend time with their baby and say goodbye. This statement acknowledges the client's emotions and offers them control over their grieving process.
Summary of Incorrect
Choices:
A: Sharing personal experiences may unintentionally minimize the client's grief and shift the focus away from them.
C: While spiritual support may be beneficial, it may not align with the client's beliefs or preferences.
D: Telling the client that the stillbirth is for the best may come off as insensitive and dismissive of their feelings, causing further distress.