ATI RN
ATI Mental Health assessment Questions
Extract:
Question 1 of 5
A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?
Correct Answer: C
Rationale: The correct answer is C: The child has had no immunizations since birth. This finding is an indicator of possible child neglect because it suggests that the child may not be receiving proper medical care and protection from preventable diseases. Neglect can manifest in various forms, including failure to provide necessary medical care such as immunizations. Failure to immunize a child puts them at risk of serious health complications and is considered a form of neglect.
Incorrect
Choices:
A: The child has a history of jaw fractures - This could indicate physical abuse rather than neglect.
B: The child seems frightened of their parent - This could indicate emotional abuse or trauma, not necessarily neglect.
D: The child rocks back and forth continually - This behavior may suggest a developmental or emotional issue, but it is not a clear indicator of neglect.
Question 2 of 5
A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available,which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Acknowledge the client's emotions. This is the first action the nurse should take because it helps establish rapport and build trust with the client in a crisis situation. Acknowledging the client's emotions shows empathy and validates their feelings, which can help de-escalate the situation. Administering a sedative (choice
A) should not be the first action as it may escalate the client's aggression. Performing a debriefing (choice
B) can wait until the immediate crisis is under control. Placing the client in restraints (choice
D) should be a last resort and only used when the client or others are in immediate danger.
Question 3 of 5
A nurse is caring for a client who has undergone electroconvulsive therapy (ECT). The nurse should monitor the client for which of the following adverse effects of ECT?
Correct Answer: C
Rationale: The correct answer is C: Memory deficit. ECT can cause short-term memory loss due to the electrical stimulation affecting the brain's functioning. The nurse should monitor the client for any signs of memory impairment post-treatment. Voice alteration (
A), neck pain (
B), and headache (
D) are less common adverse effects of ECT compared to memory deficits. It is crucial for the nurse to focus on closely monitoring the client for memory deficits as it is a prominent concern associated with ECT.
Question 4 of 5
A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?
Correct Answer: B
Rationale: The correct answer is B: A client who has repeated acute care admissions due to schizophrenia. ACT is designed for individuals with severe mental illness like schizophrenia who have difficulty engaging in traditional outpatient services. Clients with repeated acute care admissions likely need more intensive and holistic support provided by ACT teams. Referrals for major depressive disorder (choice
A) typically involve individual therapy and medication management. Family therapy (choice
C) may be appropriate for grief counseling but not necessarily for ACT. Physical injuries from partner violence (choice
D) may require medical attention and support services, but not specifically ACT.
Question 5 of 5
A nurse is planning care for a client who has major depressive disorder and is being admitted following a suicide attempt. Which of the following interventions is the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: Initiate one-to-one observation. This is the priority intervention because the client who has major depressive disorder and has attempted suicide is at high risk for self-harm. One-to-one observation provides constant monitoring and ensures the client's safety. Encouraging participation in group activities (
B) may be beneficial, but safety comes first. Administering an antidepressant (
C) is important but not the priority immediately upon admission. Setting up individual meetings (
D) can be helpful for therapy but does not address the immediate safety concern.