ATI RN Mental Health 2023 Exam 3 | Nurselytic

Correct Answer: B

Rationale: The correct answer is B. Sitting with a client who has anorexia during mealtimes can be delegated to assistive personnel as it involves providing emotional support and encouragement. This task does not require specialized nursing skills and can be safely performed by assistive personnel under the supervision of a nurse.

Choices A, C, and D involve complex assessments, critical thinking, and specialized skills that should be performed by a licensed nurse. Reinforcing coping mechanisms, discussing relapse prevention, and administering medications all require nursing judgment and expertise. Delegating these tasks to assistive personnel could compromise the quality of care and put the client's safety at risk.

Correct Answer: A

Rationale: The correct answer is A: Initiates social interactions with caregivers. For individuals with autism spectrum disorder, social skills development is a key goal. By initiating social interactions with caregivers, the adolescent can practice communication, build relationships, and enhance social functioning. This outcome focuses on improving social interaction abilities, which is crucial for the adolescent's overall well-being and integration into society.

Other choices are incorrect because:
B: Acknowledging delusions is not typically a characteristic of autism spectrum disorder.
C: Changing behavior due to peer pressure may not be appropriate or beneficial for someone with autism spectrum disorder.
D: Meeting own needs without manipulating others is a positive trait, but it is not specific to the goals of social interaction and communication targeted in this case.

Correct Answer: D

Rationale: The correct answer is D because a nurse is mandated to report any suspicion of child abuse or neglect, such as the partner tying the child to a bed. This falls under the category of child maltreatment, which must be reported to the appropriate agency to ensure the safety and well-being of the child.

Choices A, B, and C do not involve immediate harm to a vulnerable individual and do not fall under the mandated reporting requirements for nurses.

Correct Answer: D

Rationale: The correct answer is D: Determine if the client has thoughts of harming themselves. This is the first priority in this situation as the client is experiencing a situational crisis and may be at risk for self-harm or suicide. By assessing for suicidal ideation, the nurse can ensure the client's safety and initiate appropriate interventions if needed. This action takes precedence over providing coping skills teaching (
A), identifying support persons (
B), or planning follow-up visits (
C) because the client's immediate safety is the primary concern. It is crucial to address any potential risk of self-harm before proceeding with other interventions.

Correct Answer: A,D,E

Rationale: The correct answers are A, D, and E. A client with PTSD often holds persistent negative beliefs about themselves (
A) due to the trauma experienced. Difficulty falling or staying asleep (
D) is a common symptom of PTSD, as the client may experience nightmares or intrusive thoughts. Difficulty concentrating on set tasks (E) is another common finding, as the client may be easily distracted by triggers or memories related to the trauma. Talks excessively (
B) and blames others for own mistakes (
C) are not typical symptoms of PTSD and are more indicative of other conditions or personality traits.