ATI PN Mental Health Version 1| Questions and Answers with Rationales| Latest 2022/2023
1. A nurse is contributing to the plan of care for a client
... [Show More] who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting?
A. Establish rapport. (Establishing rapport is a task the nurse should perform during the orientation phase of the nurse-client relationship.)
B. Explain confidentiality and privacy. (Explaining confidentiality is a task the nurse should perform during the orientation phase of the nurse-client relationship.)
C. Reinforce teaching about medication.
D. Specify a contract. (Specifying a contract is a task the nurse should perform during the orientation phase of the nurse-client relationship.)
Rat: (Reinforcing teaching about medication is an essential component of the working phase of the nurse-client relationship that the nurse should perform. The knowledge about the client's prescribed medications prepares the client to take an active role in their care.)
2. A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence?
A. A nurse does not notify the provider of a change in condition for a client who has schizophrenia.
B. A nurse delegates an assistive personnel to sit with a client who has bulimia nervosa during mealtimes. (Sitting with a client who has bulimia nervosa during mealtime to prevent purging is an appropriate action for the nurse to delegate after ensuring the AP understands what to report to the nurse.)
C. A nurse administers an anti-anxiety medication to a restless client who has given implied consent. (The nurse should administer prescribed medications to a restless client who has given implied consent for a routine task, such as medication administration. Implied consent is a nonverbal indication that the client agrees to the treatment plan.)
D. A nurse does not document the completion of an incident report about a recent fall in the client's medical record. (The nurse should document objective information about the incident in the client's medical record. Information regarding the completion of the incident report is not documented in the client's medical record. Incident, or occurrence, reports are used as part of a quality improvement program for the facility and are not placed in the medical record. Failing to document this information in a medical record is not an example of negligence.)
Rat: (Negligence is the failure to act in a manner which follows the standard of care. The nurse should inform the provider of any changes in a client's condition. Failure to do so is considered negligence.)
3. A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions?
A. "For the first step of my therapy, I will look at pictures of cars." (This statement describes systematic desensitization, not thought stopping.)
B. "I will snap a rubber band on my wrist when I feel anxious about riding in a car."
C. "My therapist will be with me while we ride in a car together." (This statement describes modeling, not thought stopping.)
D. "I will ride in a car for several hours at a time." (This statement describes flooding, not thought stopping.)
Rat: (This statement describes thought stopping, which is used to interrupt a client's negative thought with a distraction.)
4. A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia?
A. Delusions (Positive symptoms of schizophrenia are distortions of mental health functions. False beliefs, such as delusions, are a type of positive symptom of schizophrenia.)
B. Echolalia (Echolalia, the repetition of words spoken by someone else, is a positive symptom of schizophrenia. Clients who have schizophrenia often display alterations in speech, such as echolalia.)
C. Apathy
D. Paranoia (Paranoia is an unfounded fear of others and is a positive symptom of schizophrenia.)
Rat: (Negative symptoms of schizophrenia are deficits in the client's ability to experience emotions. Apathy is a negative symptom of schizophrenia that is manifested by a loss of interest in one's surroundings.)
5. A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home. Which of the following actions should the nurse instruct the parent to take? [Show Less]