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 pose a risk for harm to self or others. Addressing visual hallucinations promptly is crucial to prevent potential injuries or dangerous behaviors. Vitamin deficiency (
A), diaphoresis (
B), and tremors (
C) are common manifestations of alcohol withdrawal but do not pose an immediate threat compared to visual hallucinations.
Therefore, visual hallucinations take precedence in prioritizing care for this client.
Question 2 of 5
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, 'I am at the end of my rope. I don't think I can take any more bad news.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct response is B: "Come with me to an area where we can talk without interruption." This option demonstrates therapeutic communication by acknowledging the client's distress and offering a supportive environment for communication. Moving to a private area allows for a more confidential and focused conversation, fostering a sense of safety and trust. This response also shows empathy and a willingness to actively listen to the client's concerns, which can help alleviate anxiety. Options A, C, and D are incorrect because they do not address the client's immediate emotional needs and may not effectively address the underlying anxiety. Option A generalizes the client's needs without actively listening, option C suggests a generic approach without considering the client's current state, and option D jumps to a medication solution without exploring the client's feelings or needs.
Question 3 of 5
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.
Question 4 of 5
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?
Correct Answer: A
Rationale:
Correct Answer: A. The client can be kept in the hospital after the 72-hour hold is over if they are a danger to themselves or others. This is based on the principle of duty to warn and protect, ensuring the safety of the client and others. This decision is made to prevent harm and provide necessary treatment.
B: This choice is incorrect because unwillingness to accept treatment does not necessarily indicate immediate danger to self or others, which is the primary concern in this scenario.
C: Liking or disliking a neighbor is not a sufficient reason to keep a client in the hospital after the 72-hour hold. It does not address the immediate safety concerns.
D: Planning to move out of state does not indicate imminent danger to self or others, which is the primary factor in determining the need for continued hospitalization.
In summary, choice A is correct because it addresses the immediate safety risk, while the other choices do not directly relate to the client's current threat level.
Question 5 of 5
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
Correct Answer: A
Rationale: The correct answer is A because warning the potential victim is crucial to ensuring their safety. By alerting the potential victim, appropriate measures can be taken to prevent harm.
Choice B is incorrect because in cases of harm to others, confidentiality can be breached to protect the safety of the potential victim.
Choice C is incorrect because immediate action is necessary, and waiting for a court order may delay intervention.
Choice D is incorrect because reporting to the psychiatrist may not be sufficient to prevent harm to the potential victim.