ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 of 5
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: The client stating "I don't feel anything but numbness anymore" indicates emotional blunting, a common symptom of clinical depression. Numbness is a sign of emotional detachment and inability to experience emotions, which is a key feature of depression. This statement suggests a significant loss of emotional responsiveness and should raise concern for depression.
Incorrect
Choices:
B: "It'll be a long time before I'm happy again" - This statement reflects a normal grieving process and does not necessarily indicate clinical depression.
C: "I feel like I'm angry at the whole world right now" - Anger can be a normal part of the grieving process and does not specifically point to clinical depression.
D: "I don't know how I could cope if I didn't have my family's support" - This statement reflects dependence on social support, which is common in bereavement but does not directly indicate clinical depression.
Question 2 of 5
A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?
Correct Answer: B
Rationale: The correct assessment the nurse should perform is B: Blood pressure. Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Monitoring the client's blood pressure is crucial to assess for any sudden increases that could indicate a potential crisis. Bowel sounds (choice
A), oxygen saturation (choice
C), and pupil response (choice
D) are not directly related to the potential side effect of consuming tyramine-rich foods.
Question 3 of 5
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?
Correct Answer: A
Rationale: The correct answer is A because assisting the client to ambulate after electroconvulsive therapy is within the scope of practice for an assistive personnel. Ambulation does not require specialized knowledge or skills, making it safe to delegate.
Choices B and C involve administering medications and obtaining informed consent, which should be done by a licensed nurse.
Choice D requires assessing the client's condition, which also falls under the nurse's responsibility.
Question 4 of 5
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?
Correct Answer: A
Rationale: The correct answer is A: "How have you dealt with similar situations in the past?" This question is essential to assess the client's personal coping skills as it explores the client's history of managing challenging situations, providing insight into their coping mechanisms and resilience. By understanding the client's past coping strategies, the nurse can tailor interventions to support the client effectively.
Choice B: "Can you describe how you are currently feeling?" focuses on the client's current emotional state rather than their coping skills.
Choice C: "Do you see your current situation affecting your future?" mainly addresses the client's perception of the future impact rather than their coping skills.
Choice D: "How does this situation affect your life?" assesses the impact of the current situation but doesn't directly address the client's coping skills.
Overall, choice A is the most appropriate as it delves into the client's coping history, aiding in the development of a comprehensive care plan.
Question 5 of 5
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior every 15 min. This is crucial to monitor the client's progress, assess the effectiveness of the seclusion, and ensure their safety. Option B is incorrect as offering food and fluids may not be appropriate during a crisis situation. Option C is incorrect as vital signs should be monitored more frequently in this scenario. Option D is incorrect as obtaining a provider's prescription is not the immediate priority in managing a client in seclusion.