ATI RN
ATI RN Mental Health 2023 III Questions
Extract:
Question 1 of 5
A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Initiate fall precautions for the client. Lorazepam is a benzodiazepine that can cause drowsiness, dizziness, and impair coordination. Initiating fall precautions is essential to prevent the client from falling and injuring themselves due to these side effects. Instructing the client to expect ringing in the ears (choice
A) is not relevant to lorazepam administration. Placing the client in restraints (choice
B) is not appropriate and can be considered a restraint of freedom. Repeating the dose in 15 minutes (choice
C) is not recommended as it can lead to an overdose.
Question 2 of 5
A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because informing the counselor about trouble sleeping is crucial in relapse prevention for schizophrenia. Sleep disturbances can signal an impending relapse, and early intervention can prevent exacerbation of symptoms.
Choice A is incorrect as encouraging listening to hallucinations can worsen symptoms.
Choice B is incorrect as isolation can lead to increased stress and exacerbation of symptoms.
Choice C is incorrect as avoiding television does not address the underlying issue.
Question 3 of 5
A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Focus the client on reality-based activities. This is appropriate as it helps ground the client in reality and distract from the hallucinations. Conveying sympathy (
A) is important but does not address the hallucinations directly. Telling the client her experience is not real (
B) may cause distress or worsen the situation. Avoiding direct questions (
C) may not address the client's needs. Option E, F, and G are not provided.
Question 4 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: D
Rationale: The correct answer is D: "We are concerned about you and need to keep you safe." This response demonstrates empathy, acknowledges the client's feelings, and prioritizes safety. It conveys the nurse's duty to ensure the client's well-being and addresses the client's demand for privacy without compromising safety.
A: Offering a contract may not be effective in preventing harm, as suicidal ideation is a serious issue that requires continuous monitoring.
B: While medication levels are important, constant observation is necessary in this situation to prevent any potential harm.
C: Submitting the request to the provider may delay necessary intervention and compromise the client's safety.
E, F, G: No information provided.
Question 5 of 5
A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?
Correct Answer: B
Rationale: The correct answer is B: A translator of the same gender as the client. This choice is the most appropriate because it ensures effective communication while also considering the client's comfort and cultural sensitivity. The translator will help bridge the language barrier, ensuring accurate understanding and expression of thoughts and feelings. Choosing a translator of the same gender can further enhance the client's comfort level and promote trust within the group. This option prioritizes clear communication and respects the client's needs.
Choice A is not ideal as the unit secretary may not have the necessary language proficiency for effective communication.
Choice C, another client, may not be reliable or appropriate for maintaining confidentiality.
Choice D, a family member, could introduce potential conflicts of interest and may not be impartial.