ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
Correct Answer: D
Rationale: Acknowledging the client’s emotions without confrontation helps de-escalate the situation.
Question 2 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 3 of 5
A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Move the client to a private area so the conversation will not be disturbed. This action is important to ensure the safety and privacy of both the client and the nurse. Moving the client to a private area can help de-escalate the situation by reducing external stimuli that may exacerbate the client's aggression. It also allows for a more confidential and therapeutic interaction. In contrast, the other options may not effectively address the client's escalating aggression. Using clarification (
B) may be useful but does not address the immediate safety concern. Speaking authoritatively (
C) may escalate the situation further. Maintaining eye contact (
D) can be perceived as confrontational and may further agitate the client.
Question 4 of 5
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). NMS is a rare but life-threatening side effect of antipsychotic medications like haloperidol. The client's symptoms of high fever, elevated blood pressure, and muscle rigidity are classic signs of NMS. The nurse should suspect NMS due to the acute onset of these symptoms in a client taking haloperidol.
A) Agranulocytosis is a potential side effect of antipsychotic medications but does not present with the same symptoms as NMS.
B) Akathisia is characterized by restlessness and does not typically involve fever or muscle rigidity.
C) Tardive dyskinesia is a movement disorder that develops with long-term antipsychotic use and does not present acutely with fever and elevated blood pressure.
Therefore, the correct choice is D as it aligns with the client's presentation and medication history.
Question 5 of 5
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of being "fine" despite having traumatic injuries suggest denial, a defense mechanism where the individual refuses to acknowledge the reality of their situation. This reaction is common in individuals facing overwhelming or distressing events as a way to cope with the emotional impact. Displacement (
B) involves redirecting emotions towards a substitute target, Projection (
C) involves attributing one's own unacceptable feelings to others, and Undoing (
D) involves trying to undo or reverse a previous action to alleviate guilt. In this scenario, denial best fits the client's behavior.