ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Medical History
The client is 19 years old, has severe anxiety, and was admitted to an inpatient mental health facility for observation and behavioral therapy two weeks ago. The client’s weight at the time of admission was 54.4 kg (120 lb). The client reported sleeping 3 to 4 hours per night due to recurrent nightmares, as well as a decrease in appetite. The client’s family member stated that the client had separated themselves from friends, refused to leave their house, and picked their skin until it bled. The client’s family member also mentioned that there is a family history of anxiety. The client reported previous participation in cognitive-behavioral therapy.
Nurses’ Notes
Nurses’ Notes The client appears to be well-groomed. The client’s current weight is 54 kg (119 lb). The client states they are sleeping 5 to 6 hours per night but are having occasional nightmares. The client verbalizes a decreased appetite and gastrointestinal discomfort. The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.” The client verbalizes that bullying experienced during high school has led to anxiety. The client engages in thought-stopping behavioral therapy and cognitive restructuring. The client reports taking escitalopram 20 mg daily, 2 hours after breakfast.
Medication Administration Record
• Escitalopram 20 mg once daily
Question 1 of 5
A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility one week ago.Exhibits: A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect, click on the finding again
Correct Answer: A, B, E, F
Rationale: The correct answers are A, B, E, F. A well-groomed appearance indicates self-care and improved mental state. Sleeping 5-6 hours with occasional nightmares suggests improved sleep patterns. Engaging in thought-stopping behavioral therapy and cognitive restructuring shows active participation in treatment. Reporting medication compliance with escitalopram indicates following the prescribed treatment plan.
Choices C and D indicate ongoing symptoms and concerns, while choice G focuses on past triggers rather than current improvement.
Extract:
Question 2 of 5
A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Ask the client if he intends to harm others. This is the priority action because it directly addresses the safety of the other clients. By assessing the client's intentions, the nurse can determine the level of risk and take appropriate measures to prevent harm.
Choice A is incorrect because exploring stress reduction techniques is not the immediate priority when there is a risk of harm to others.
Choice B is incorrect as role modeling healthy ways to express anger is not as urgent as addressing the current aggressive behavior.
Choice D is incorrect as making a list of things that make the client angry does not address the immediate safety concerns of the other clients.
Overall, the priority in this situation is to assess the client's intentions to prevent harm to others.
Question 3 of 5
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client's spiritual needs?
Correct Answer: D
Rationale: The correct answer is D. Offering to contact the client's spiritual advisor shows support for the client's spiritual needs, providing them with an opportunity to seek comfort and guidance from someone who shares their beliefs. This action respects the client's autonomy and individual preferences. It acknowledges the importance of spirituality in the grieving process, which can provide solace and coping mechanisms.
Options A, B, and C are incorrect:
A: Encouraging the client to internalize their feelings may hinder the grieving process and inhibit emotional expression, potentially leading to unresolved issues.
B: Changing the subject when the client expresses anger dismisses their emotions and prevents them from processing their feelings effectively.
C: Allowing the client to be alone during times of spiritual inadequacy may exacerbate feelings of isolation and hinder their ability to seek support and comfort.
Question 4 of 5
A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Implement measures to prevent intentional self-inflicted injury. This is the priority because individuals with borderline personality disorder are at high risk for self-harm behaviors. Preventing harm to the client is the most immediate concern to ensure their safety and well-being. Encouraging support group attendance (
A) and discussing assertive behavior (
B) are important but not as critical as preventing self-injury. Assisting the client to maintain awareness of thoughts and feelings (
D) is also important but not the priority in this case.
Question 5 of 5
A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?
Correct Answer: A
Rationale: The correct answer is A. A client with mania often exhibits rapid and excessive talking, a common symptom of mania. This behavior is known as pressured speech. Option B, memory loss, is not typically associated with mania but may occur in certain situations. Option C, sleeping over 10 hours a day, is more indicative of depression rather than mania. Option D, expressing feelings of inferiority, is more aligned with symptoms of depression, not mania.