ATI RN
ATI Mental Health assessment Questions
Extract:
Question 1 of 5
A nurse is caring for an adult client who is receiving treatment for alcohol use disorder. The client is upset because his partner has refused to visit him in the treatment facility. Which of the following actions by the client should indicate to the nurse that the client is using regression as a defense mechanism?
Correct Answer: D
Rationale: The correct answer is D because stomping feet and throwing objects are behaviors associated with regression, which is a defense mechanism where an individual reverts to earlier, childlike behaviors in response to stress. This behavior is a way for the client to release pent-up emotions and frustrations in a less mature manner.
Choice A is incorrect because sudden hearing loss is more indicative of conversion disorder.
Choice B is incorrect as it reflects rationalization, a defense mechanism where excuses are made to justify behavior.
Choice C is incorrect as yelling obscenities is more related to acting out, another defense mechanism where emotions are expressed through actions rather than words.
Question 2 of 5
A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider,which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Correct Answer: C
Rationale: Conducting a debriefing regarding the client with the unit staff is essential in ensuring continuity of care, discussing the client's behavior, potential triggers, and strategies for de-escalation. This promotes a collaborative approach and enhances staff awareness to prevent future aggressive behaviors. It also allows for sharing insights and improving the care plan.
Incorrect Answers:
A: Documenting the client's behavior once every hour is important for monitoring, but it does not address the need for a debriefing or evaluation.
B: Keeping the client in restraints until the prescription expires is not appropriate as restraints should be used for the shortest duration necessary and reevaluated regularly.
D: Requesting an evaluation of the client within 12 hours of restraint application is important, but it does not address the immediate need for debriefing and collaboration with unit staff.
Question 3 of 5
A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?
Correct Answer: C
Rationale: The correct answer is C: Reluctance to discuss the event that precipitated the distress. This is expected in individuals with PTSD as they often avoid talking about or reliving the traumatic event. This avoidance behavior is a common symptom of PTSD and is included in the diagnostic criteria. Individuals with PTSD may experience intrusive thoughts or memories related to the trauma, which can be distressing and lead to avoidance behaviors. This manifestation is important for the nurse to assess as it can impact the client's ability to engage in therapy and treatment.
Explanation of other choices:
A: Decreased startle response to loud noises - This is not typically seen in individuals with PTSD, as they often have an exaggerated startle response due to hypervigilance.
B: Reports uninterrupted sleep of 10 to 12 hr each night - Sleep disturbances are common in PTSD, such as nightmares or difficulty falling asleep.
D: Reports feelings of acute distress that began to 2 weeks ago - PTSD symptoms must persist for more
Question 4 of 5
A nurse on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has illness anxiety disorder?
Correct Answer: A
Rationale: The correct answer is A because it reflects the characteristic excessive worry and fear of having a serious medical condition seen in illness anxiety disorder. The client's behavior of repeatedly checking for lumps despite negative results aligns with the excessive health-related concerns typical of this disorder.
Choice B is more indicative of a potential issue with pregnancy tests.
Choice C suggests paranoia rather than illness anxiety disorder.
Choice D reflects generalized anxiety rather than excessive health-related concerns.
Question 5 of 5
A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)
Correct Answer: B,C,E
Rationale: The correct manifestations for delirium in a client with sepsis are rapid mood changes, hallucinations, and restlessness. Rapid mood changes can be seen due to the fluctuating mental status in delirium. Hallucinations are common in delirium and can present as visual, auditory, or tactile. Restlessness is a common behavioral manifestation in delirium, often accompanied by agitation. Slow speech (choice
A) is not typically associated with delirium but rather with conditions affecting speech production. Unaltered level of consciousness (choice
D) is not correct as delirium is characterized by a fluctuating level of consciousness.