ATI RN
ATI Mental Health assessment Questions
Extract:
Question 1 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.
Question 2 of 5
A charge nurse is providing education to a group of newly-licensed nurses about the rights of clients who are involuntarily admitted. Which of the following responses by a newly-licensed nurse indicates understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: These clients can vote in local and federal elections. Involuntary admission does not negate an individual's right to vote. This response indicates understanding of the teaching because it recognizes the importance of upholding clients' rights to participate in the democratic process. The other choices are incorrect because:
A: Inspecting packages does not relate to the rights of involuntarily admitted clients.
B: Participation in a research study is not related to the rights of involuntarily admitted clients.
D: Involuntarily admitted clients have the right to refuse medications unless a court order is obtained.
Question 3 of 5
A nurse is providing teaching to a client who has a prescription for disulfiram. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A: If I drink alcohol I will become very sick. This statement indicates an understanding of the teaching because disulfiram is a medication used to treat alcohol use disorder by causing unpleasant effects if alcohol is consumed. Becoming very sick is one of the main side effects of drinking alcohol while taking disulfiram.
Choice B is incorrect because difficulty falling asleep is not a common side effect of disulfiram.
Choice C is incorrect as disulfiram does not affect inhibitions in the way described.
Choice D is incorrect as severe mood swings are not a typical side effect of disulfiram.
Question 4 of 5
A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?
Correct Answer: B
Rationale:
Correct Answer: B. Ensure the client's ex-partner is notified of the threat.
Rationale: The nurse has a legal duty to protect potential victims by notifying the ex-partner to prevent harm. This action upholds the duty to warn principle, safeguarding the well-being of others. Keeping the client hospitalized indefinitely (
A) is not ethically sound and violates the client's rights. Asking a friend or family member to monitor the client (
C) may not ensure the ex-partner's safety. Transfer to a mental health facility (
D) may be necessary but does not directly address the immediate threat.
Question 5 of 5
A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply.)
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. Grandiosity is a common behavior in manic episodes where the client exhibits an inflated sense of self-importance. Flight of ideas refers to rapid and disconnected thoughts. Hyperactivity is manifested by increased physical movement and restlessness. Splitting, choice C, is a defense mechanism associated with borderline personality disorder, not bipolar disorder. Withdrawal, choice E, is more indicative of depressive episodes rather than manic episodes.
Therefore, the correct choices are A, B, and D based on the typical behaviors exhibited during a manic episode of bipolar disorder.