Mental Health ATI RN

Extract:

Question 1 of 5

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

Correct Answer: D

Rationale: As a mandated reporter the nurse must document and report suspected abuse to protect the child. Discussing with parents risks further harm direct questioning may intimidate and consulting a coworker delays action.

Question 2 of 5

The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

A. A client who bursts into tears leaves the group meeting and sits on the bed hugging a pillow and sobbing B. A client who stomps away from the nurses' station goes into the day room and grabs a pool cue from another client standing at the pool table C. A client who tells the primary nurse 'When you told me that I could not have a pass I felt angry.' D. A client who tells the medication nurse 'I am not going to take that or any other medication.'

Correct Answer: B

Rationale: Grabbing a pool cue after stomping away indicates hostility and potential violence defining aggression. Crying verbalizing anger or refusing medication do not involve aggressive actions.

Question 3 of 5

An alert oriented older adult client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which reason does the nurse identify is most likely why the client has not reported the abuse?

A. Laws do not provide protection against abuse when the suspect(s) is/are family members. B. The client has no financial resources to hire legal representation against the client's children. C. The client is emotionally close to the children and does not want to bring them harm. D. The client cannot claim abuse if there is no evidence of physical harm.

Correct Answer: C

Rationale: Emotional closeness and fear of harming family often prevent reporting abuse. Laws protect against family abuse financial barriers are secondary and abuse includes non-physical forms.

Question 4 of 5

A client is informed by the nurse that they must take their medication and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

A. The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist. B. The nurse throws the medication in the trash and documents the client refuses the medication. C. The nurse pushes the client and the client falls to the floor and sustains a nosebleed. D. The nurse goes to the client's room and applies restraints then forces the medication in the client's mouth.

Correct Answer: D

Rationale: False imprisonment involves unlawfully restricting a person’s freedom. Applying restraints and forcing medication without justification violates the client’s rights constituting false imprisonment. Other actions involve communication documentation or assault not restraint.

Question 5 of 5

A client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

A. Malpractice B. Battery C. False imprisonment D. Assault

Correct Answer: A

Rationale: Malpractice refers to a legal claim that can be made against healthcare professionals including nurses and hospitals when they fail to provide the standard of care expected in their profession resulting in harm or injury to a patient. In this case the lack of documentation that the client was assessed every hour as prescribed can be seen as a failure to meet the standard of care for a client with depression at risk for self-harm. This failure may have contributed to the client's suicide attempt constituting malpractice. Battery false imprisonment and assault do not apply as there was no intentional contact restraint or threat.

Mental Health ATI RN | Nurselytic

Nurselytic

ATI RN

ATI RN