ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: "We are concerned about you and need to keep you safe." This response acknowledges the client's feelings while emphasizing the nurse's duty to ensure safety. It communicates empathy and concern, which can help build trust. It also sets clear boundaries and reinforces the importance of monitoring for safety in a non-confrontational manner.
Choice A is incorrect because it does not address the immediate safety concerns of the client. Submitting the request to the provider may delay necessary interventions.
Choice C is incorrect as safety contracts are not evidence-based practices and may provide a false sense of security.
Choice D is incorrect as constant observation is not necessary once safety measures have been implemented unless there is an immediate threat.
In summary, choice B is the most appropriate response as it balances empathy with the need for safety and establishes a supportive therapeutic relationship.
Extract:
Provider Prescriptions
Olanzapine 10 mg tablet, taken orally daily.
Alprazolam 1 mg tablet, taken orally three times daily as needed for anxiety.
Nurses’ Notes
The client reports hearing voices that are discussing race cars and race tracks. The client appears diaphoretic and pale. The client also reports a weight gain of 2.2 kg (4.9 lb) in the past week.
Graphic Record
Blood Pressure (BP): 128/82 mm Hg
Pulse Rate: 98/min
Respiratory Rate: 20/min
Temperature: 39.4° C (103° F)
Oxygen Saturation (SaO2): 95%
Question 2 of 5
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Correct Answer: B
Rationale:
Step 1: The nurse should report the client's temperature to the provider because it could indicate a potential infection or other physical health issue.
Step 2: Changes in temperature can impact overall health and may require medical intervention.
Step 3: Hallucinations are common in schizophrenia and may not necessarily require immediate medical attention.
Summary: Weight gain and blood pressure can be side effects of medications used to treat schizophrenia. Hallucinations are a common symptom of the disorder and may not always be alarming. Temperature, however, is a vital sign that can indicate a physical health concern requiring prompt attention.
Extract:
Question 3 of 5
A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will place a sliding bolt lock just above the doorknob." This indicates an understanding of the teaching because it demonstrates a proactive measure to prevent the client from wandering and getting lost. The sliding bolt lock can help secure the door and prevent the client from leaving the house unsupervised.
Choice A is incorrect because waiting 2 hours to notify law enforcement may result in delays in finding the client.
Choice B is incorrect as providing a photo to the police is important but does not actively prevent the client from wandering.
Choice D is irrelevant to home safety and Alzheimer's disease management.
Extract:
2045
• X-ray of left wrist
• Hydrocodone 2.5 mg/acetaminophen 325 mg, 2 tablets PO now
2345:
• Discharge to home.
• Follow-up with orthopedist, their office will call tomorrow.
• Keep left arm elevated with splint on.
• Ice left wrist per written instructions provided.
• Ibuprofen 800 mg PO every 8 hr PRN pain
Medical History
• Premenstrual dysphoric disorder
• No known allergies
Physical Examination 2030
• Left wrist injury and edema
• Finger-shaped bruises on the left forearm
• Reports pain with movement of left wrist and hand as 8 on a 0 to 10 pain scale, and pain as 6 at rest. Grimacing and tearfulness noted with movement. Fingers warm with capillary refill less than 2 seconds.
2145:
• Reports left wrist pain as 6 with movement and as 4 at rest on a 0 to 10 pain scale.
Nurses’ Notes 2030
• Client presents for evaluation of left wrist injury reportedly following an incident of partner violence. The client states their partner had been drinking heavily prior to the physical altercation. The client reports the partner roughly grabbed their left arm while yelling loudly in their face. The client was able to free their arm and was walking to their car to leave when the partner aggressively pushed the client from behind. The client fell forward, using both arms to brace their fall. The client states the partner saw their wrist injury and began crying and apologizing, promising to never drink again. The client states, “I’ve heard that promise so many times, but they’ve never cried before, so I think it is sincere this time.”
• Left arm elevated on 2 pillows. Ice pack applied to left wrist.
2045:
• Provider in to see client. Prescriptions received.
2145:
• Client returned to room from radiology department via wheelchair. Left arm elevated and ice pack reapplied. A law enforcement officer in to talk with client after receiving a 911 call from the client’s neighbor who witnessed the physical altercation.
2330:
• Client declines to press charges against partner, per report of law enforcement officer. The client agreed to a social services referral, appointment scheduled for tomorrow. Discussed safety plan with client and the client reports having an envelope of important papers already hidden at home. Also provided the client with the phone numbers for the local crisis hotline and safe house. The client is receptive to information but states, “I need to work on my relationship a while longer. I really think things will get better this time.”
Question 4 of 5
A nurse in an emergency department is caring for a client who recently experienced partner violence.Exhibits:The nurse is reviewing the client’s medical record at discharge. For each finding, specify whether the finding indicates a potential improvement in or a worsening of the client’s physical or psychological status.
| Options | Indicates potential improvement | Indicates potential worsening |
|---|---|---|
| Client states that the partner will not be violent in the future. | ||
| Client agrees to an appointment with a social worker. | ||
| Client's reported pain level of the left wrist. | ||
| Client requests help developing a safety plan. | ||
| Client claims responsibility for the physical altercation. |
Correct Answer:
Rationale: [1, 0, 0]
Correct Answer: A: Client states that the partner will not be violent in the future.
Rationale: This indicates a potential improvement in the client's physical and psychological status as it suggests a commitment to a non-violent future.
Summary: B: Client agrees to an appointment with a social worker - While beneficial, it does not directly address future violence. C: Client's reported pain level of the left wrist - Focuses only on physical aspect. D: Client requests help developing a safety plan - Indicates awareness of potential danger but not future behavior. E: Client claims responsibility for the physical altercation - May not indicate a change in future violence.
Extract:
Question 5 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 attributing their blackouts to a seemingly logical and acceptable cause (low blood sugar) rather than acknowledging the true underlying issue of dissociative identity disorder. Rationalization involves creating logical explanations or justifications for behaviors, thoughts, or feelings that are otherwise unacceptable. In this case, the client is using rationalization to avoid facing the uncomfortable reality of their dissociative symptoms.
Incorrect choices:
A: Suppression involves consciously avoiding or pushing away thoughts or feelings. This does not apply to the client's situation.
B: Sublimation involves channeling unacceptable impulses into more socially acceptable behaviors. This is not demonstrated in the client's statement.
C: Projection involves attributing one's own thoughts or feelings to others. This is not evident in the client's statement.
Therefore, rationalization is the most appropriate defense mechanism being used by the client in this scenario.