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ATI RN Mental Health Online Practice 2019 B (Retake 2023) Questions with All Correct Answers| Rationale in All Choices |Guarantee A+ Score Guide A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a bo...

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  • March 4, 2023
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ATI RN Mental Health Online Practice 2019 B (Retake 2023) A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issues? A. An adolescent family member who question s parental authority B. A family with three generations in the same household C. Older children who are responsible for their younger siblings D. Two adults and their children from prior relationships in the same household {{Correct Ans - C - This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members. A - incorrect - An adolescent who questions parental authority is demonstrating appropriate behaviors for developmental age B - incorrect - This scenario occurs in many households, not indication of boundary issue D. This is an example of a blended family, not indication of boundary issue A nurse is performing an admission assessment on a client and notices that the client appears withdrawn an d fearful. To establish a trusting nurse=client relationship, which of the following actions should the nurse take first? A. Inform the client that this admission is confidential B. Introduce the client to other clients in the day room C. Assist the cli ent in facilitating behavioral change D. Determine coping strategies that the client used in the past {{Correct Ans - A - - According to evidence -based practice, the nurse should first inform the client about confidentiality during the orientation p hase of the nurse -client relationship. B - Incorrect The nurse should introduce the client to other clients in the day room to help the client interact with others during the working phase of the nurse -client relationship. However, evidence -based practice indicates that the nurse should take a different action first. C. INCORRECT The nurse should assist the client with behavioral change during the working phase of the nurse -client relationship. However, evidence -based practice indicates that the nurse shou ld take a different action first. D. Incorrect The nurse should determine what coping strategies the client used in the past during the working phase of the nurse -client relationship. However, evidence -
based practice indicates that the nurse should take a different action first. A nurse is performing a cognitive assessment to distinguish delirium form dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? A. Slow onset B. Aphasia C. Confabulation D. Easily distracted {{Correct Ans - D - - Extreme distractibility is a hallmark manifestation of delirium. A - INCORRECT Delirium has an acute onset. Dementia is a slow, progressive decline. B. INCORRECT Aphasia is a manifestation of dementia C. INCORRECT Confabulation is a manifestation of dementia. A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? A. Offer the client various choices for meal selection B. Assign different nursing personnel for each shift C. Permit the client to perform daily rituals to decrease anxiety D. Maintain an environment that has low lighting {{Correct Ans - C - The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals. A- INCORRECT The nurse should provide a client who has delirium with a plan of care that d ecreases agitation and anxiety by limiting the choices the client is asked to make. B - The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing consistent nursing personnel. D - The nurse sho uld provide a client who has delirium with a plan of care that decreases agitation and anxiety by providing a well -lit environment. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventi ons should the nurse include in the plan of care? A. Encourage the client to participate in group therapy B. Instruct the client to avoid napping during the day C. Offer the client high -calorie finger foods frequently D. Decrease the client's daily fibe r intake {{Corre ct Ans - C - The nurse should frequently offer the client high -calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydra tion. A - INCORRECT The nurse should maintain a low -stimuli environment for a client who is experiencing mania. The nurse should dim the lights, decrease noise, and limit the number of people the client is around. B - The nurse should encourage the client to take frequent rest periods throughout the day. Clients experiencing mania are at risk of exhaustion that can be life threatening. D - The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients experiencing mania can e xperience dehydration and nutritional deficiencies from decreased intake, which can lead to constipation. A nurse is teaching the partner of a client who has bipolar disorder how to identify acute mania. Which of the following findings should the client's partner report to the provider? A. Obsessive attention to detail B. Inability to sleep C. Reports of fatigue D. Isolation from others {{Correct Ans - B - During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding A - INCORRECT During the manic phase of bipolar disorder, a client's behavior becomes disorganized and chaotic, which renders the client unable to focus on detail. C - INCORRECT Although the client who is experiencing acute mania might eventually become exhausted, there is a characteristic unawareness of fatigue during this phase.

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