ATI RN Mental Health Practice 2019 A (V1) |60 Questions and Verified Answers with Rationales ()
QUESTION
A nurse in the emergency department is caring
... [Show More] for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?
Gather supplies for endotracheal intubation.
Administer a beta blocker intravenously.
Position the client in a low-Fowler's position.
Place a cooling blanket over the client.
Answer:
Gather supplies for endotracheal intubation.
The nurse should gather supplies for endotracheal intubation because an expected finding of an unresponsive client who has alcohol toxicity is respiratory depression.
Administer a beta blocker intravenously.
QUESTION
A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?
"It will be better for you to keep busy to avoid thinking about your child's death."
"You will complete the grieving process about a year after your child's death."
"The grief process will start once your child actually dies."
"It is not uncommon to feel angry toward yourself or others."
Answer:
"It is not uncommon to feel angry toward yourself or others."
Feelings of blame and anger towards oneself or others are an expected reaction when a client is experiencing a loss.
QUESTION
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?
Move the client to a room near the nurses' station.
Limit visitors until the client is oriented to the environment.
Tell the client that their partner is deceased.
Talk with the client about activities they enjoyed with their partner.
Answer:
Talk with the client about activities they enjoyed with their partner.
Talking about positive experiences can help distract the client from their disorientation.
QUESTION
A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?
Increased confusion
Sleep disturbances
Cluttered environment
Inappropriate dress
Answer:
Inappropriate dress
Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect.
QUESTION
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?
Promote the use of music to compete with the client's auditory hallucinations.
Inform the client that the auditory hallucinations are not real.
Avoid asking the client if they are experiencing auditory hallucinations.
Instruct the client on the use of voice recognition regarding the auditory hallucinations.
Answer:
Promote the use of music to compete with the client's auditory hallucinations.
Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level.
QUESTION
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
"I put in extra hours at work so I won't think about drinking."
"I know that wine is good for my heart, so that's why I drink some each evening."
"I make up for my drinking by taking my partner on nice vacations."
"I am able to go to work every day, so I don't have a problem."
Answer:
"I am able to go to work every day, so I don't have a problem."
By insisting that their drinking is not a problem because they can go to work every day, the client is using the defense mechanism of denial. This allows the client to ignore the existence of their substance use disorder.
QUESTION
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?
Total body fat 8.7%
Potassium 3.6 mEq/L
Temperature 35.8° C (96.4° F)
Heart rate 54/min
Answer: [Show Less]