ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A, B, C
Rationale: The correct manifestations to include are A (Seizures), B (Illusions), and C (Tremors). Seizures commonly occur during alcohol withdrawal due to central nervous system hyperexcitability. Illusions are perceptual distortions that can occur as a result of alcohol withdrawal. Tremors are a common physical symptom of alcohol withdrawal, often seen in the hands.
Choice D (Polyphagia) refers to excessive hunger, which is not typically associated with alcohol withdrawal.
Choice E (Nystagmus) is an involuntary eye movement that is not a common manifestation of alcohol withdrawal. The key is to focus on symptoms directly related to alcohol withdrawal to provide accurate teaching to the client.
Question 2 of 5
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.
Question 3 of 5
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
Correct Answer: A
Rationale: The correct answer is A: Protecting the client from injury. This is the highest priority because ensuring the client's physical safety is essential during a crisis intervention for acute anxiety. If the client is at risk of harming themselves or others, immediate action must be taken to prevent any harm. Options B, C, and D are important aspects of care but ensuring physical safety takes precedence in this situation. Determining the cause of anxiety, ensuring the client feels safe, and identifying coping skills are important but can be addressed once the immediate risk of harm is addressed.
Question 4 of 5
A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse’s assessment priority?
Correct Answer: C
Rationale: The correct assessment priority in this scenario is suicide risk (
C). This is because the client's reported symptoms of feeling depressed, sad, moody, and overly anxious indicate a potential risk of self-harm or suicide. Assessing for suicide risk is crucial to ensure the client's safety and well-being. Coping abilities (
A) and support systems (
B) are important factors to consider but assessing suicide risk takes precedence in this situation. Psychiatric history (
D) may provide valuable information but is not as urgent as assessing for immediate safety concerns.
Question 5 of 5
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. This action promotes open communication and allows the nurse to provide support and guidance to help the client manage her urge to overexercise. It also helps in monitoring the client's behavior and intervening when necessary to prevent harm.
Choice A is incorrect because praising the client for looking at herself in a mirror may reinforce unhealthy behaviors associated with body image.
Choice C is incorrect as reprimanding the client may increase feelings of shame and guilt, worsening the situation.
Choice D is incorrect because restricting the client from being weighed may not address the underlying issue of overexercising.