ATI RN
ATI RN Mental Health 2019 NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Monitor the child's vital signs every 15 min. This is crucial when using restraints to ensure the child's safety and well-being. Monitoring vital signs can help detect any signs of distress or complications promptly.
Choice B is incorrect as obtaining a prescription for restraints is not time-sensitive.
Choice C is incorrect as range-of-motion exercises may not be appropriate or safe in this situation.
Choice D is incorrect as ensuring three fingers fit between the wrist and restraint is important for proper fit but does not address immediate safety monitoring.
Question 2 of 5
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
Correct Answer: A
Rationale: The correct answer is A: Displacement. The client is displacing his anger towards his partner onto the nurse by becoming angry and telling her to leave. Displacement is a defense mechanism where one redirects an emotion from its original source to a less threatening target. In this case, the client is unable to express his anger towards his partner directly, so he directs it towards the nurse. Rationalization (
B) is creating logical explanations for behavior, not applicable here. Denial (
C) is refusing to accept reality, which is not demonstrated. Compensation (
D) is making up for a perceived weakness by emphasizing a strength, not relevant in this scenario.
Question 3 of 5
A nurse is conducting an admission interview with a new client who tells the nurse, 'My life is so stressful. I can't take it anymore.' Which of the following responses should the nurse make first?
Correct Answer: B
Rationale:
Correct Answer: B - "Are you thinking of harming yourself?"
Rationale: This response is crucial as it directly addresses the client's statement about not being able to take the stress anymore. It shows the nurse's immediate concern for the client's safety and well-being. By asking about self-harm, the nurse can assess the client's risk level and provide appropriate support or intervention if needed.
Incorrect
Choices:
A: "How have you dealt with stress in the past?" - This question focuses on the past and does not address the immediate risk of self-harm.
C: "Tell me what makes you feel stressed." - While understanding stress triggers is important, it does not address the client's current state of distress.
D: "Let's talk more about what you are experiencing." - This response does not directly address the potential risk of self-harm and may delay addressing the client's immediate needs.
Question 4 of 5
A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Reassure staff members that the debriefing is confidential. This intervention should be taken first because it creates a safe and trusting environment for staff to openly express their feelings and experiences without fear of judgment or repercussions. Confidentiality helps build psychological safety, which is crucial for effective debriefing. Asking staff to describe traumatic memories (
A) could trigger distress without proper support. Having staff discuss their involvement (
B) might be overwhelming without first ensuring confidentiality. Providing stress-management exercises (
D) is important but should come after establishing trust and safety.
Question 5 of 5
A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?
Correct Answer: B
Rationale: The correct answer is B. The client stating that he is unable to eat more than once a day is the priority finding because it indicates potential malnutrition and poor physical health due to grief. This is a critical concern that needs immediate attention to prevent further health complications.
Choice A focuses on guilt, which is important but not immediate.
Choices C and D involve emotional distress but do not address the client's physical well-being.
Therefore, they are not the priority at this time.