ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?
Correct Answer: C
Rationale: Borderline personality disorder is strongly linked to self-harm. Bulimia (
A) is less directly related, parental disorder (
B) is not a specific risk, and promotion (
D) is positive.
Question 2 of 5
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
Correct Answer: B
Rationale: Disorganized speech indicates acute mania, characterized by racing thoughts. Weight gain (
A), hallucinations (
C), and clothing choice (
D) are not specific to mania.
Question 3 of 5
A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?
Correct Answer: D
Rationale: Weekly blood tests during the first month monitor lithium levels to prevent toxicity. Stopping for diarrhea (
A), empty stomach (
B), and low-salt diet (
C) are incorrect.
Question 4 of 5
A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Removing harmful objects minimizes self-harm risk. Twelve-hour observation (
A) may be insufficient, and unregulated visitors (C,
D) risk bringing harmful items.
Extract:
A nurse in a mental health facility is caring for a client.
Medical History: Antisocial personality disorder.
Substance use disorder.
Nurses' Notes:. 1400: Client admitted to facility by court order for evaluation following arrest for disorderly conduct and resisting arrest.
Client states, "That judge is so stupid.
I don't belong here!" Client has rigid posture, is pacing around the room attempting to intimidate staff and other clients on the unit.
Extra staff members gather.
1500: Client escorted to room.
Client becomes flirtatious with assistant personnel (AP). Client introduced to roommate, whom they ignore.
Continues to flirt with AP. 1800: Client refuses to go to dining room for dinner.
States, "I'm not sitting down with a bunch of nuts.
Question 5 of 5
Bring my food to me!". For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
| anticipated | contraindicated |
|---|---|
| Use bargaining to improve behavior. | |
| Provide rewards for positive behavior. | |
| Ignore negative behavior. | |
| Maintain a low-stimuli environment. |
Correct Answer:
Rationale: Rewards for positive behavior (
B) and low-stimuli environment (
D) are anticipated for antisocial personality disorder. Bargaining (
A) reinforces manipulation, and ignoring negative behavior (
C) avoids accountability.