ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 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: D
Rationale: The correct answer is D: "You will need to have your blood drawn." This response is correct because lithium is a medication that requires monitoring of blood levels due to its narrow therapeutic range. Lethargy, muscle weakness, and blurred vision are symptoms of lithium toxicity, which can occur if the blood levels of lithium become too high. By having the client's blood drawn, the nurse can assess the lithium levels and make necessary adjustments to the dosage to prevent further toxicity.
Incorrect Responses:
A: "These symptoms will improve over time." - This is incorrect because the symptoms described are indicative of lithium toxicity, which requires immediate attention.
B: "Continue the medication as prescribed." - This is incorrect because if the client is experiencing symptoms of toxicity, continuing the medication without monitoring could lead to further complications.
C: "You should decrease your intake of sodium." - This is incorrect as it does not address the issue of lithium toxicity. Sodium intake is not directly related to lithium toxicity.
Question 2 of 5
A nurse is caring for a client who has a substance use disorder. The client states, 'The state took my child away after my overdose. I don’t want to go on living without them.' Which of the following therapeutic responses should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "Have you thought about harming yourself?" This response demonstrates active listening and shows concern for the client's safety, which is a priority when assessing suicidal ideation. Asking directly about self-harm can open up a dialogue for further assessment and intervention. It also allows the nurse to gauge the client's risk level and provide appropriate support or referrals.
Choice A is incorrect because it implies a conditional agreement that may not be achievable solely through counseling.
Choice B is inappropriate as prescribing sedatives without addressing the underlying issues is not therapeutic.
Choice D does not address the immediate safety concern and may not be feasible or safe.
Question 3 of 5
A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, 'I think my blackouts are actually caused by low blood sugar.' The nurse should recognize the client is using which of the following defense mechanisms?
Correct Answer: D
Rationale: The correct answer is D: Rationalization. The client is using rationalization by attributing their blackouts to low blood sugar instead of acknowledging the possibility of dissociative identity disorder. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical explanations to avoid facing uncomfortable truths. In this scenario, the client is rationalizing their blackouts as a result of low blood sugar, which is a more socially acceptable reason compared to accepting the diagnosis of dissociative identity disorder.
Suppression (
A) involves consciously pushing unwanted thoughts or feelings out of awareness. Sublimation (
B) is redirecting unacceptable impulses into socially acceptable activities. Projection (
C) is attributing one's own thoughts or feelings onto others. In this case, the client is not using these defense mechanisms.
Question 4 of 5
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B
Rationale:
Correct Answer: A, B
Rationale:
A: Identifying the client's stressors is important to understand the underlying cause of the behavior and helps in addressing the root issue.
B: Talking to the client using short, simple sentences can help in de-escalating the situation and ensuring effective communication.
C: Speaking to the client in a loud voice may escalate the situation further by increasing agitation and aggression.
D: Requesting security guards to restrain the client should be a last resort and may lead to physical harm and trauma.
E: Standing directly in front of the client can be perceived as confrontational and may escalate the situation further.
Question 5 of 5
A nurse is caring for a client who has a depressive disorder. The client states, 'I don’t always go to bed at night, so I get in trouble for falling asleep at work.' Which of the following interventions should the nurse recommend?
Correct Answer: C
Rationale: Rationale for Correct Answer C: Keeping a sleep diary to promote a consistent sleep schedule is the most appropriate intervention. By tracking sleep patterns, the client and nurse can identify underlying issues impacting sleep and work together to establish a structured routine. This intervention promotes sleep hygiene and helps regulate the client's sleep-wake cycle, potentially improving sleep quality and work performance.
Summary for Incorrect Answers:
A: Taking a 1-hour nap every day may disrupt the client's circadian rhythm and worsen insomnia.
B: Exercising late in the day can increase alertness and make it harder for the client to fall asleep at night.
D: Discontinuing medication without medical guidance can be dangerous and may exacerbate the client's depressive symptoms.