ATI RN
ATI Mental Health assessment Questions
Extract:
Question 1 of 5
A nurse is reviewing the medical record of a newly admitted client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for this condition?
Correct Answer: A
Rationale: The correct answer is A: The client has a serotonin deficiency. Serotonin is a neurotransmitter linked to mood regulation, and a deficiency can contribute to the development of major depressive disorder. Serotonin imbalance is a well-known risk factor for depression.
Choices B, C, and D are not directly related to major depressive disorder. Acute bronchitis and elevated calcium levels do not have a direct association with depression. Being an only child is also not a recognized risk factor for major depressive disorder.
Therefore, option A is the most relevant and plausible risk factor for major depressive disorder in this scenario.
Question 2 of 5
A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?
Correct Answer: B
Rationale:
Correct
Answer: B. Ensure the client's ex-partner is notified of the threat.
Rationale: The nurse has a legal duty to protect potential victims by notifying the ex-partner to prevent harm. This action upholds the duty to warn principle, safeguarding the well-being of others. Keeping the client hospitalized indefinitely (
A) is not ethically sound and violates the client's rights. Asking a friend or family member to monitor the client (
C) may not ensure the ex-partner's safety. Transfer to a mental health facility (
D) may be necessary but does not directly address the immediate threat.
Question 3 of 5
A nurse in an acute care facility is assessing a client who has schizophrenia. The client states,Walk tall broom short dag bell. The nurse should document the client's speech as which of the following speech patterns?
Correct Answer: B
Rationale: The correct answer is B: Word salad. This speech pattern is characterized by jumbled and incoherent words that do not form logical sentences. In this case, the client's speech is a mixture of unrelated words, indicating disorganized thinking commonly seen in schizophrenia. Flight of ideas (
A) involves rapid, continuous, and disconnected thoughts. Neologisms (
C) are newly created words that have meaning only to the client. Clang associations (
D) are words grouped together based on their sound rather than meaning. These options do not align with the client's speech pattern of word salad.
Question 4 of 5
A nurse is assessing an older adult client's ability to make a successful role transition to widowhood following the death of her partner. Which of the following factors should the nurse include in the assessment? (Select all that apply.)
Correct Answer: B,C,D,,E
Rationale: The correct factors to include in the assessment for the older adult client's successful role transition to widowhood are: B, C, D, and E. Firstly, the client's willingness to attend a support group (
B) is important for accessing emotional support. Secondly, the client's current health status (
C) is crucial as it can impact their ability to cope with the transition. Thirdly, the client's family support system (
D) plays a key role in providing practical and emotional support during this difficult time. Lastly, the client's involvement in a spiritual community (E) can provide additional sources of comfort and support.
Incorrect choices:
A: The client's advance directives status - While important for healthcare decision-making, it is not directly relevant to the client's transition to widowhood.
F: Blank choice - This is not a valid response as it does not provide any relevant information.
G: Blank choice - Same as choice F, it does not contribute to the assessment of the client
Question 5 of 5
A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider,which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Correct
Answer: C
Rationale: Conducting a debriefing regarding the client with the unit staff is essential in ensuring continuity of care, discussing the client's behavior, potential triggers, and strategies for de-escalation. This promotes a collaborative approach and enhances staff awareness to prevent future aggressive behaviors. It also allows for sharing insights and improving the care plan.
Incorrect Answers:
A: Documenting the client's behavior once every hour is important for monitoring, but it does not address the need for a debriefing or evaluation.
B: Keeping the client in restraints until the prescription expires is not appropriate as restraints should be used for the shortest duration necessary and reevaluated regularly.
D: Requesting an evaluation of the client within 12 hours of restraint application is important, but it does not address the immediate need for debriefing and collaboration with unit staff.