ATI RN
ATI Mental Health 2023 II Questions
Extract:
Question 1 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A,B,D
Rationale:
Correct
Answer: A, B, D
Rationale:
A: Putting locks at the top of doors can prevent the client from wandering outside at night, reducing the risk of falls.
B: Positioning the mattress on the floor minimizes the risk of injury in case the client falls out of bed during the night.
D: Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, ensuring their safety.
Summary of Incorrect
Choices:
C: Encouraging physical activity prior to bedtime may increase the client's agitation and restlessness, leading to more wandering.
E: Placing the client in a reclining chair does not address the issue of wandering and falls, and may not provide adequate safety measures.
Question 2 of 5
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Document the client’s refusal of the treatment in the medical record. This is the appropriate action because it respects the client's autonomy and right to refuse treatment. It ensures that the refusal is documented for legal and ethical purposes.
Choice A is incorrect as involving the client's family without consent violates confidentiality and autonomy.
Choice B is incorrect as ECT does require informed consent.
Choice D is incorrect because the client, even if involuntarily committed, has the right to refuse treatment.
Question 3 of 5
A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?
Correct Answer: D
Rationale: The correct answer is D: Reports a lack of sleep. In acute mania, individuals typically experience decreased need for sleep or insomnia. This symptom is crucial in diagnosing acute mania as it is a hallmark feature of the manic phase in bipolar disorder. It is important for the nurse to recognize this sign as it can lead to further exacerbation of manic symptoms and potential harm to the client.
A: Isolating oneself from others is a symptom of depression, not acute mania.
B: Writing a detailed daily activity schedule is a positive coping mechanism and does not necessarily indicate acute mania.
C: Refusing to engage in conversation could be a sign of social withdrawal, but it is not specific to acute mania.
In summary, reporting a lack of sleep is the key indicator of acute mania, while the other choices are more indicative of different mental health states or coping strategies.
Question 4 of 5
A nurseorius caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Inform the client that they have the legal right to refuse treatment at any time. This is the correct action because clients have the autonomy to make decisions about their own healthcare, including the right to refuse treatment. By informing the client of this right, the nurse respects the client's autonomy and ensures they are fully informed. Obtaining consent from a family member (
A) is not appropriate as the client is capable of making their own decisions. Requesting another nurse to review the procedure with the client (
B) may not address the client's concerns about the procedure. Encouraging the client to have the procedure (
C) goes against the client's autonomy and choice.
Question 5 of 5
A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, 'I can’t think about that until after my first grandchild is born next week.' The nurse should identify the client’s statement as indicating the maladaptive use of which of the following defense mechanisms?
Correct Answer: C
Rationale: The correct answer is C: Suppression. The client is using suppression, a maladaptive defense mechanism, to temporarily avoid dealing with the distressing news of their cancer diagnosis by focusing on their upcoming grandchild's birth. Suppression involves consciously pushing unwanted thoughts or feelings out of awareness. It differs from sublimation (
A), which involves channeling unacceptable impulses into socially acceptable activities, compensation (
B), which involves making up for perceived weaknesses by emphasizing strengths, and regression (
D), which involves reverting to an earlier stage of development under stress. In this scenario, the client's statement does not align with these defense mechanisms, making suppression the most appropriate choice.