ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?
Correct Answer: D
Rationale: The correct answer is D: Maintain a low level of environmental stimuli. Command hallucinations are auditory hallucinations that instruct the individual to perform certain actions. By reducing environmental stimuli, the nurse can help minimize triggers that may exacerbate the hallucinations. This intervention aims to create a calming and safe environment for the client, reducing the likelihood of responding to the hallucinations. Providing reassurance through touch (choice
A) may not address the underlying issue of hallucinations and could potentially be triggering. Encouraging increased socialization (choice
B) may overwhelm the client and increase stress. Avoiding eye contact (choice
C) may create a barrier in communication and trust-building. Overall, maintaining a low level of environmental stimuli is the most appropriate intervention to support the client in managing command hallucinations.
Question 2 of 5
A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Give the client a choice of solitary activities. This is appropriate for a client with schizoid personality disorder, who typically prefers solitary activities and may struggle with social interactions. By offering a choice of solitary activities, the nurse is respecting the client's preferences and promoting a sense of autonomy and comfort.
A: Identifying splitting behaviors is more relevant for clients with borderline personality disorder, not schizoid personality disorder.
C: Setting limits on social contact is not appropriate as individuals with schizoid personality disorder typically prefer solitude.
D: Assisting the client in identifying sources of anger is more relevant for clients with other personality disorders characterized by emotional dysregulation.
In summary, option B is the best choice as it aligns with the needs and preferences of a client with schizoid personality disorder.
Question 3 of 5
A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: 'It must be difficult for you to feel this way after losing your partner.' This response is empathetic and acknowledges the partner's feelings without invalidating them. It shows understanding and support without imposing judgment. Option A shares a personal experience, which may not be relevant or helpful to the partner. Option C is directive and may not be the partner's immediate need. Option D, though positive, may come across as dismissive of the partner's feelings.
Question 4 of 5
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client's spiritual needs?
Correct Answer: D
Rationale: The correct answer is D. Offering to contact the client's spiritual advisor shows support for the client's spiritual needs, providing them with an opportunity to seek comfort and guidance from someone who shares their beliefs. This action respects the client's autonomy and individual preferences. It acknowledges the importance of spirituality in the grieving process, which can provide solace and coping mechanisms.
Options A, B, and C are incorrect:
A: Encouraging the client to internalize their feelings may hinder the grieving process and inhibit emotional expression, potentially leading to unresolved issues.
B: Changing the subject when the client expresses anger dismisses their emotions and prevents them from processing their feelings effectively.
C: Allowing the client to be alone during times of spiritual inadequacy may exacerbate feelings of isolation and hinder their ability to seek support and comfort.
Question 5 of 5
A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Implement measures to prevent intentional self-inflicted injury. This is the priority because individuals with borderline personality disorder are at high risk for self-harm behaviors. Preventing harm to the client is the most immediate concern to ensure their safety and well-being. Encouraging support group attendance (
A) and discussing assertive behavior (
B) are important but not as critical as preventing self-injury. Assisting the client to maintain awareness of thoughts and feelings (
D) is also important but not the priority in this case.