ATI RN
ATI RN Mental Custom Health Next Gen Questions
Extract:
Question 1 of 5
Which nursing statement is an example of reflection?
Correct Answer: B
Rationale: The correct answer is B. This statement demonstrates reflection as it involves paraphrasing and repeating back the patient's words to show understanding. By restating, "So you are saying that life has no meaning," the nurse is reflecting the patient's feelings and thoughts accurately.
Choice A is more of a personal opinion.
Choice C shows confusion rather than reflection.
Choice D is an observation rather than reflecting the patient's feelings.
Question 2 of 5
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
Correct Answer: A
Rationale: The correct answer is A: Place in a side-lying position with head of bed elevated. This intervention is crucial in preventing aspiration and maintaining a patent airway in a client with a high BAL and altered level of consciousness due to the head injury. Placing the client in a side-lying position helps protect the airway by preventing the tongue from obstructing it. Elevating the head of the bed further aids in preventing aspiration.
Choice B is incorrect because administering disulfiram is not indicated in this situation as it is used for treating alcohol dependence, not acute intoxication.
Choice C is incorrect as giving lorazepam can worsen the client's level of consciousness and respiratory status.
Choice D is incorrect because while thiamine and folate are important in alcohol withdrawal treatment, they are not the priority in this scenario where airway protection is crucial.
Question 3 of 5
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
Correct Answer: A
Rationale: The correct answer is A because attempting to physically restrain an aggressive client can escalate the situation and potentially result in harm to both the client and the mental health worker. It is crucial for the RN to intervene immediately to prevent any physical confrontation and ensure safety for all individuals involved.
Choice B is incorrect because maintaining a safe distance from an aggressive client is a recommended practice to ensure personal safety.
Choice C is incorrect as guiding the client to a quiet area can be a de-escalation technique.
Choice D is incorrect as using a loud voice may be necessary to communicate effectively in a tense situation. It is important to prioritize safety and de-escalation techniques when caring for clients with escalating aggressive behavior.
Question 4 of 5
A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?
Correct Answer: A
Rationale: The correct answer is A: Assist the client to a safe area to avoid injury. This is the most appropriate intervention because the client is engaging in potentially harmful behaviors such as vigorous exercise and crashing into furniture. By moving the client to a safe area, the nurse can prevent any physical harm that may result from the client's actions.
Choice B: Establish clear and firm limits with the client may not be effective in this situation as the client may not be receptive to verbal communication due to their current behavior.
Choice C: Offer medication to help calm the client down may not be appropriate as it is important to address the immediate safety concerns first before considering medication.
Choice D: Speak with the client in a calm, non-threatening manner may not be effective in this situation as the client is not in a state to engage in a calm conversation.
In summary, choice A is the most appropriate intervention to ensure the client's safety in the current situation.
Question 5 of 5
Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient’s nursing diagnosis is altered thought processes?
Correct Answer: C
Rationale: The correct answer is C: "You say you hear voices, what are they telling you?" This response acknowledges the patient's experience without dismissing it or imposing the nurse's reality. It shows empathy and encourages the patient to express their thoughts, facilitating therapeutic communication.
Choice A fails to acknowledge the patient's experience and may come off as dismissive.
Choice B is directive and denies the reality of the patient's experience, potentially causing distress.
Choice D is also directive and may alienate the patient.
Choices E, F, and G are not provided, but they would likely be incorrect if they fail to address the patient's altered thought processes in a nonjudgmental and empathetic manner.