ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?
Correct Answer: B
Rationale: The correct answer is B: Establish confidentiality guidelines with the client. This is the first step in building a trustful nurse-client relationship, especially in mental health settings where privacy is crucial. By setting clear confidentiality guidelines, the nurse ensures the client's information is kept confidential, fostering a sense of safety and trust. This initial step lays the foundation for open communication and collaboration between the nurse and the client.
Choice A is incorrect because assisting the client with coping strategies comes after establishing trust and confidentiality.
Choice C is incorrect as helping the client make behavioral changes is a later stage in the therapeutic process.
Choice D is incorrect because sharing information about the disorder should come after the trust has been established and confidentiality guidelines have been discussed.
Question 3 of 5
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B
Rationale:
Correct
Answer: A, B
Rationale:
A: Identifying the client's stressors helps address the root cause of the behavior and provides insight into how to support the client effectively.
B: Talking to the client using short, simple sentences can help de-escalate the situation by promoting clear communication and reducing confusion.
Incorrect
Choices:
C: Speaking to the client in a loud voice can escalate the situation further, increasing agitation and distress.
D: Requesting security guards to restrain the client should be a last resort as it can lead to physical harm and worsen the client's emotional state.
E: Standing directly in front of the client can be perceived as confrontational and may increase the client's feelings of being trapped or threatened.
Question 4 of 5
A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?
Correct Answer: A
Rationale: The correct answer is A: Identify the client's current stage of grief. This is the priority because understanding the client's stage of grieving will guide the nurse in providing appropriate interventions and support. By identifying the stage, the nurse can tailor the care plan to address specific needs and challenges the client may be facing. Understanding where the client is in the grieving process will also help in assessing the client's coping mechanisms and potential risks. Encouraging physical activities (
B) may be beneficial but not as crucial as understanding the client's current stage of grief. Discussing the use of a spiritual grief counselor (
C) or informing the client about expected feelings of anger (
D) are important interventions but should come after identifying the client's stage of grief.
Question 5 of 5
A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express their feelings. This is important because it allows the client to process their emotions, reduce feelings of isolation, and promote a sense of validation. By expressing their feelings, the client can better cope with anticipatory grief associated with dementia. Providing a timeline (choice
A) might not be helpful as grief is a unique process for each individual. Showing sympathy (choice
C) is important, but encouraging the client to express their feelings is more directly beneficial. Sharing personal stories (choice
D) can shift the focus away from the client's needs. The other choices are not relevant to addressing the client's emotional needs in this situation.