ATI RN
ATI RN Mental Health 2019 NGN Questions
Extract:
Question 1 of 5
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
Correct Answer: C
Rationale: The nurse should see the client taking clozapine and reporting a sore throat first. This is because clozapine can cause agranulocytosis, a serious adverse effect that presents with sore throat and fever. Immediate assessment and intervention are crucial to prevent complications. Clients with bipolar disorder speaking loudly (
A) may not require immediate attention unless it indicates agitation or aggression. Weight gain from lithium (
B) is a common side effect that can be addressed later. Olfactory hallucinations in schizophrenia (
D) are concerning but not immediately life-threatening compared to the potential complications of agranulocytosis.
Question 2 of 5
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Reacting to the nurse as though she were his mother. This behavior indicates transference, where the client projects feelings or attitudes towards the nurse that are actually related to someone else from their past, typically a parent. This is common in clients with personality disorders. Refusing to participate in group activities (
A) may be related to social anxiety or avoidance, not necessarily transference. Talking negatively about staff members (
B) and expressing frustration regarding unit rules (
D) are not specific to transference and can be seen in various situations.
Question 3 of 5
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
Correct Answer: C
Rationale: Countertransference occurs when a healthcare provider projects their own feelings or experiences onto a client. In this scenario, option C, "The client is just like my brother who finally overcame his habit," demonstrates countertransference. The staff nurse is drawing a parallel between the client and their brother, which can affect their judgment and care for the client. This statement implies a personal connection that may cloud the nurse's objectivity. Options A, B, and D are not examples of countertransference as they focus on the client's behavior, responsibility, and boundaries, respectively. It is important for healthcare providers to recognize and address countertransference to ensure unbiased and effective care.
Question 4 of 5
A nurse is conducting an admission interview with a new client who tells the nurse, 'My life is so stressful. I can't take it anymore.' Which of the following responses should the nurse make first?
Correct Answer: B
Rationale:
Correct Answer: B - "Are you thinking of harming yourself?"
Rationale: This response is crucial as it directly addresses the client's statement about not being able to take the stress anymore. It shows the nurse's immediate concern for the client's safety and well-being. By asking about self-harm, the nurse can assess the client's risk level and provide appropriate support or intervention if needed.
Incorrect
Choices:
A: "How have you dealt with stress in the past?" - This question focuses on the past and does not address the immediate risk of self-harm.
C: "Tell me what makes you feel stressed." - While understanding stress triggers is important, it does not address the client's current state of distress.
D: "Let's talk more about what you are experiencing." - This response does not directly address the potential risk of self-harm and may delay addressing the client's immediate needs.
Question 5 of 5
A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Reassure staff members that the debriefing is confidential. This intervention should be taken first because it creates a safe and trusting environment for staff to openly express their feelings and experiences without fear of judgment or repercussions. Confidentiality helps build psychological safety, which is crucial for effective debriefing. Asking staff to describe traumatic memories (
A) could trigger distress without proper support. Having staff discuss their involvement (
B) might be overwhelming without first ensuring confidentiality. Providing stress-management exercises (
D) is important but should come after establishing trust and safety.