ATI RN Mental Health 2023 III

Extract:

Question 1 of 5

A nurse is receiving change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?

A. A client who has narcissistic personality disorder B. A client who has mild anxiety disorder C. A client who has severe obsessive-compulsive disorder D. A client who has conversion disorder

Correct Answer: D

Rationale: The correct answer is D because clients with conversion disorder may present with sensory impairments, such as blindness or paralysis, without a clear medical cause. The nurse should assess for these impairments to provide appropriate care.

Choices A, B, and C do not necessarily require specific assessments related to sensory impairments.
Choice A is associated with self-centeredness, choice B with excessive worry, and choice C with compulsive behaviors.
Therefore, the nurse should focus on assessing client D for sensory impairments to address their unique needs.

Question 2 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?

A. Encourage the client to express their feelings B. Share personal stories of grief with the client C. Provide the client with a timeline for grieving D. Show sympathy for the client when discussing their condition

Correct Answer: A

Rationale: The correct answer is A: Encourage the client to express their feelings. This is crucial because allowing the client to talk about their emotions can help them process their grief and feel supported. Sharing personal stories (
B) may not be appropriate as it shifts the focus from the client. Providing a timeline (
C) for grieving is not effective as everyone grieves differently. Showing sympathy (
D) is important, but encouraging expression of feelings is more proactive in supporting the client.

Question 3 of 5

A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?

A. Discuss the use of a spiritual grief counselor with the client B. Identify the client's current stage of grief C. Inform the client that feelings of anger are expected D. Encourage the client to participate in physical activities

Correct Answer: C

Rationale: The correct answer is C: Inform the client that feelings of anger are expected. This is the priority because acknowledging and normalizing the client's emotions, such as anger, is crucial in the grieving process. It helps the client feel validated and understood, promoting emotional healing. Discussing the use of a spiritual grief counselor (
A) may be helpful, but addressing the client's immediate emotional needs comes first. Identifying the client's current stage of grief (
B) is important, but addressing their feelings of anger takes precedence. Encouraging participation in physical activities (
D) may be beneficial for overall well-being, but it does not directly address the client's emotional turmoil.

Question 4 of 5

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

A. Instruct the client to expect ringing in the ears B. Place the client in restraints for 1 hour C. Repeat the dose in 15 minutes if the client is still anxious D. Initiate fall precautions for the client

Correct Answer: D

Rationale: The correct answer is D: Initiate fall precautions for the client. Lorazepam is a benzodiazepine that can cause drowsiness, dizziness, and impair coordination. Initiating fall precautions is essential to prevent the client from falling and injuring themselves due to these side effects. Instructing the client to expect ringing in the ears (choice
A) is not relevant to lorazepam administration. Placing the client in restraints (choice
B) is not appropriate and can be considered a restraint of freedom. Repeating the dose in 15 minutes (choice
C) is not recommended as it can lead to an overdose.

Question 5 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)

A. Speak to the client in a loud voice B. Stand directly in front of the client C. Request that security guards restrain the client D. Talk to the client using short, simple sentences E. Identify the client's stressors

Correct Answer: D, E

Rationale:
Correct
Answer: D, E

Rationale:
1. Talking to the client using short, simple sentences helps in calming the client down as complex information may escalate the situation.
2. Identifying the client's stressors allows the nurse to address the underlying causes of the behavior and provide appropriate support.
Summary:
A: Speaking loudly can escalate the situation further.
B: Standing directly in front may be perceived as confrontational, worsening the behavior.
C: Involving security guards may increase agitation and escalate the situation.
D: Talking using short, simple sentences can help de-escalate and communicate effectively.
E: Identifying stressors helps address root causes and provide appropriate support.

ATI RN Mental Health 2023 III | Nurselytic

Nurselytic

ATI RN

ATI RN