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: Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. A calm and quiet environment can help reduce the intensity and frequency of hallucinations, providing a sense of safety and reducing stress and anxiety.
Touch may be misinterpreted, group therapy might overwhelm, and avoiding eye contact, while useful, is less critical than minimizing stimuli.
Question 2 of 5
A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?
Correct Answer: C
Rationale: Attending to personal hygiene addresses self-care neglect common in BPD during distress, improving function. Mood improvement is vague, hallucinations aren’t typical, and communication isn’t BPD-specific.
Question 3 of 5
A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, 'I think my blackouts are actually caused by low blood sugar.' The nurse should recognize the client is using which of the following defense mechanisms?
Correct Answer: D
Rationale: Rationalization justifies blackouts with a logical but false reason (low blood sugar) rather than the psychological cause. Suppression, sublimation, and projection don’t fit.
Extract:
Medical History
The client was diagnosed with obsessive-compulsive disorder 4 years ago.
Nurses’ Notes
Day 1 of admission at 1300:
The client is withdrawn, exhibits a flat affect, and makes limited eye contact with others. The client’s clothing is dirty and body odor is noted. The client reports sleeping 2 to 3 hours per night and losing 5.4 kg (12 lb) in the last month. The client also reports handwashing for several minutes multiple times per day. The client’s hands are noted to be red, but the skin is intact. The client is constantly folding and unfolding a small piece of paper during conversation. The client refuses to leave the room or eat lunch and declines the offer to watch a movie in the day room with peers. The client also declines the offer to take a shower at this time.
Day 3 of admission at 1835:
The client showered this morning without prompting. The client ate 75% of lunch and dinner in the day room with peers. The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. The client was overheard speaking to their sibling on the phone a few minutes ago, telling their sibling they could have the client’s car.
Provider Prescriptions
Day 1 of admission: Fluvoxamine 100 mg PO at bedtime Buspirone 10 mg PO twice daily Paroxetine 20 mg PO daily
Question 4 of 5
A nurse on an inpatient mental health unit is caring for a client.Exhibits:The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.
| Options | Indicates potential improvement | Indicates potential worsening |
|---|---|---|
| Giving away car | ||
| Hygiene | ||
| Food intake | ||
| Condition of skin on right hand | ||
| Rapid change in mood |
Correct Answer:
Rationale: Giving away car (
A) suggests worsening (suicidal risk), hygiene (
B) and food intake (
C) improve (showering, eating 75%), skin (
D) worsens (excessive washing), mood change (E) improves (content, talkative).
Extract:
Provider Prescriptions
Olanzapine 10 mg tablet, taken orally daily.
Alprazolam 1 mg tablet, taken orally three times daily as needed for anxiety.
Nurses’ Notes
The client reports hearing voices that are discussing race cars and race tracks. The client appears diaphoretic and pale. The client also reports a weight gain of 2.2 kg (4.9 lb) in the past week.
Graphic Record
Blood Pressure (BP): 128/82 mm Hg
Pulse Rate: 98/min
Respiratory Rate: 20/min
Temperature: 39.4° C (103° F)
Oxygen Saturation (SaO2): 95%
Question 5 of 5
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Correct Answer: B
Rationale: Temperature of 39.4°C (103°F) indicates fever, needing urgent attention over hallucinations (expected), weight gain (common with olanzapine), or normal BP (128/82 mmHg).