ATI RN Mental Health 2019 NGN UPDATED 2024
Total Questions : 63
Showing 25 questions, Sign in for moreA nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?
Explanation
Answer is:Assist the client to ambulate for the first time following the procedure.
Explanation: This is a task that the nurse can delegate to an assistive personnel (AP) because it is within the scope of practice of an AP and it does not require direct supervision by the nurse.Ambulating a client who is postoperative can help prevent complications such as deep vein thrombosis, pneumonia, and pressure ulcers1.
Statement is wrong because:
- Check the client’s condition after the procedure. This is a task that the nurse should perform because it requires direct observation and assessment of the client’s response to electroconvulsive therapy (ECT).The nurse should also monitor for any adverse effects such as nausea, headache, muscle soreness, or memory loss2.
- Witness the client’s signature on the consent for the procedure. This is a task that the nurse should perform because it involves obtaining informed consent from the client or their legal representative.The nurse should explain the purpose, benefits, risks, and alternatives of ECT to the client and answer any questions they may have3.
- Give the client atropine 30 min before the procedure. This is a task thatthe nurse should not delegateto an AP because it requires direct administration of medication and monitoring of vital signs.Atropine is used as an antiarrhythmic agent to prevent cardiac arrest during ECT4.
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?
No explanation
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?
No explanation
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?
No explanation
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
No explanation
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
No explanation
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Explanation
Choice A rationale:
Documenting the client's behavior every 15 minutes is a valid nursing action when a client is placed in seclusion. However, it is not the most critical step to take in this situation. The safety and well-being of the client and staff are paramount, and obtaining the provider's prescription is more crucial.
Choice B rationale:
The correct choice. Obtaining the provider's prescription within 60 minutes is essential when a client is placed in seclusion. Seclusion is an intervention that restricts the client's freedom, and it should only be done under the supervision of a licensed healthcare provider. The nurse must obtain a prescription for this intervention as soon as possible to ensure that the client's rights and safety are respected.
Choice C rationale:
Offering the client food and fluids every 2 hours is a valid nursing action in a seclusion situation. However, it is not the most immediate priority. Obtaining the provider's prescription takes precedence to ensure the appropriateness of the intervention.
Choice D rationale:
Monitoring the client's vital signs every 4 hours is an important nursing action, but it is not the primary step to take immediately after placing a client in seclusion. Obtaining the provider's prescription is more urgent to ensure the legality and appropriateness of the intervention.
A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?
Explanation
Choice A rationale:
While it's true that many people feel ashamed to tell their secrets, this response does not actively encourage the client to open up about their feelings. It acknowledges the feeling but does not promote a therapeutic conversation.
Choice B rationale:
Encouraging the client to tell the nurse what they did might not be the most appropriate response. The client might not be ready to disclose their actions and pushing them to do so could lead to further distress. It's important to establish trust and create a safe space for the client before delving into specific details.
Choice C rationale:
The correct choice. This response is empathetic and supportive while also gently encouraging the client to discuss their feelings. It opens the door for the client to share at their own pace and lets them know that the nurse is willing to listen without judgment.
Choice D rationale:
While it's true that the client shouldn't feel embarrassed to talk to the nurse, this response doesn't actively address the client's feelings or concerns. It's more important to provide a response that acknowledges the client's emotions and invites open communication.
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?
No explanation
A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?
No explanation
A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?
Explanation
The correct answer is Choice C: Determine the immediate safety needs of the child.
Choice A rationale: Reporting suspected abuse to Child Protective Services is an important step in cases of suspected child abuse. However, before taking this action, it is crucial to ensure the immediate safety and well-being of the child. Jumping directly to reporting without assessing the immediate safety needs could potentially put the child at further risk if they are left in a dangerous situation. Therefore, while reporting suspected abuse is necessary, it is not the first action the nurse should take in this scenario.
Choice B rationale: Requesting that the parent leave the room while interviewing the child may be necessary to ensure the child feels comfortable and able to speak freely. However, before conducting the interview, it is essential to address any immediate safety concerns. Additionally, removing the parent from the room may not always be feasible or appropriate, especially if the child requires immediate medical attention or protection. Therefore, while this action may be taken at some point, it is not the first action the nurse should take.
Choice C rationale: Determining the immediate safety needs of the child is the first and most critical action the nurse should take in this scenario. This involves assessing the severity of the injury, evaluating if the child is in immediate danger, and taking any necessary steps to ensure their safety and well-being. This could include providing medical treatment, removing the child from a dangerous environment, or contacting emergency services if needed. By addressing the immediate safety needs first, the nurse can ensure the child's well-being before further investigating the situation.
Choice D rationale: Asking the child how the injury occurred is an important step in gathering information about the incident. However, before conducting the interview, it is essential to prioritize the child's safety and well-being. Jumping directly to questioning without assessing the immediate safety needs could potentially further traumatize the child or put them at risk if they are in a dangerous situation. Therefore, while interviewing the child is necessary, it should not be the first action taken by the nurse.
In conclusion, Choice C, determining the immediate safety needs of the child, is the first action the nurse should take in this scenario to ensure the child's well-being and safety are prioritized.
A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?
No explanation
A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?
No explanation
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?
No explanation
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
No explanation
A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?
No explanation
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?
No explanation
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
Explanation
The correct answer is c. Reacting to the nurse as though she were his mother.
Choice A rationale:
- Refusing to participate in group activities can be a sign of social anxiety,withdrawal,or other mental health issues,but it's not specifically indicative of transference.
- Individuals with personality disorders may withdraw from social interactions for various reasons,such as fear of rejection,discomfort in social settings,or a preference for isolation.
- While refusal to participate in group activities could be a manifestation of transference in some cases,it's not the most typical or defining characteristic.
Choice B rationale:
- Talking negatively about other staff members can occur due to dissatisfaction with treatment,personality traits,or interpersonal conflicts.
- It's not directly related to transference,which involves projecting feelings and expectations from past relationships onto current ones.
- While individuals with personality disorders may engage in negative talk about others,this behavior doesn't necessarily stem from transference.
Choice C rationale:
- Reacting to the nurse as though she were his mother is a classic example of transference.
- In this case,the client is unconsciously transferring feelings,thoughts,and behaviors associated with his mother onto the nurse.
- This can manifest in various ways,such as seeking excessive attention or reassurance from the nurse,becoming overly dependent on her,or reacting with anger or hostility if she doesn't meet his expectations.
- This behavior is a key indicator that the client is using transference as a coping mechanism.
Choice D rationale:
- Expressing frustration regarding unit rules can be a sign of difficulty with authority or adjusting to the structure of a treatment setting.
- It's not inherently a sign of transference,as it doesn't involve projecting feelings from past relationships onto the current one.
- Individuals with personality disorders may struggle with rules and authority,but this behavior is not a direct manifestation of transference.
An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?
Explanation
The correct answer is Choice d. "Tell me the reasons you think your mother is depressed."
Rationale for Choice a. "Everyone gets depressed from time to time."
- This response is dismissive and minimizes the daughter's concerns. It suggests that depression is not a serious condition and does not warrant professional attention.
- It fails to acknowledge the daughter's feelings of worry and anxiety.
- It does not gather any information about the mother's symptoms or the reasons for the daughter's concern.
Rationale for Choice b. "Older adults are usually diagnosed with depressive disorder as they age."
- While it is true that depression is more common in older adults, this response does not address the daughter's concerns about her mother's specific symptoms.
- It may unnecessarily alarm the daughter by suggesting that depression is an inevitable part of aging.
- It does not encourage the daughter to share her observations and concerns.
Rationale for Choice c. "You shouldn't worry about this, because depressive disorder is easily treated."
- This response is premature and potentially misleading. It offers reassurance without first gathering enough information to determine whether the mother is actually depressed.
- It may discourage the daughter from sharing important details about her mother's condition.
- It implies that treatment for depression is always simple and straightforward, which is not always the case.
Rationale for Choice d. "Tell me the reasons you think your mother is depressed."
- This response is the most appropriate because it encourages the daughter to share her observations and concerns.
- It demonstrates that the nurse is taking the daughter's concerns seriously.
- It allows the nurse to gather more information about the mother's symptoms and the potential reasons for her depression.
- It opens the door to further assessment and discussion, which are essential for accurate diagnosis and treatment planning.
A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity?
No explanation
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
No explanation
A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?
No explanation
A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?
No explanation
A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?
No explanation
A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
No explanation
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