ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
A client with paranoid personality disorder is admitted to a psychiatric facility.
Which remark by the nurse would best establish rapport and encourage the
client to confide in the nurse?
A) "I get upset once in a while, too."
B) "I know just how you feel. I'd feel the same way in your situation."
C) "I worry, too, when I think people are talking about me."
D) "At times, it's normal not to trust anyone."
Sharing a benign, nonthreatening, personal fact or feeling helps the nurse
establish rapport and encourages the client to confide in the nurse. The
nurse can't know how the client feels. Telling the client otherwise, as in
option B, would justify the suspicions of a paranoid client; furthermore, the
client relies on the nurse to interpret reality. Option C is incorrect because it
focuses on the nurse's feelings, not the client's. Option D wouldn't help
establish rapport or encourage the client to confide in the nurse.
A client with paranoid schizophrenia repeatedly uses profanity during an activity
therapy session. Which response by the nurse would be most appropriate?
A) "Your behavior won't be tolerated. Go to your room immediately."
B) "You're just doing this to get back at me for making you come to therapy."
C) "Your cursing is interrupting the activity. Take time out in your room for 10
minutes."
D) "I'm disappointed in you. You can't control yourself even for a few minutes."
The nurse should set limits on client behavior to ensure a comfortable
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
, ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
environment for all clients. The nurse should accept hostile or quarrelsome
client outbursts within limits without becoming personally offended, as in
option A. Option B is incorrect because it implies that the client's actions
reflect feelings toward the staff instead of the client's own misery.
Judgmental remarks, such as option D, may decrease the client's self-
esteem.
The nurse is caring for a client with schizophrenia. Which of the following
outcomes is the least desirable?
A) The client spends more time by himself
B) The client doesn't engage in delusional thinking
C) The client doesn't harm himself or others
D) The client demonstrates ability to meet his own self-care needs
The client with schizophrenia is commonly socially isolated and withdrawn;
therefore, having the client spend more time by himself wouldn't be a
desirable outcome. Rather, a desirable outcome would specify that the client
spend more time with other clients and staff on the unit. Delusions are false
personal beliefs. Reducing or eliminating delusional thinking using talking
therapy and antipsychotic medications would be a desirable outcome.
Protecting the client and others from harm is a desirable client outcome
achieved by close observation, removing any dangerous objects, and
administering medications. Because the client with schizophrenia may have
difficulty meeting his or her own self-care needs, fostering the ability to
perform self-care independently is a desirable client outcome.
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
, ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
The nurse formulates a nursing diagnosis of Impaired verbal communication for
a client with schizotypal personality disorder. Based on this nursing diagnosis,
which nursing intervention is most appropriate?
A) Helping the client to participate in social
interactions B) Establishing a one-on-one
relationship with the client
C) Establishing alternative forms of communication
D) Allowing the client to decide when he wants to participate in verbal
communication with the nurse
By establishing a one-on-one relationship, the nurse helps the client learn how to interact with
people in new situations. The other options are appropriate but should take place only after
the nurse-client relationship is established.
Since admission 4 days ago, a client has refused to take a shower, stating,
"There are poison crystals hidden in the showerhead. They'll kill me if I take a
shower." Which nursing action is most appropriate?
A) Dismantling the showerhead and showing the client that there is nothing in it
B) Explaining that other clients are complaining about the client's body odor
C) Asking a security officer to assist in giving the client a shower
D) Accepting these fears and allowing the client to take a sponge bath
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
, ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
By acknowledging the client's fears, the nurse can arrange to meet the
client's hygiene needs in another way. Because these fears are real to the
client, providing a demonstration of reality (as in option A) wouldn't be
effective at this time. Options B and C would violate the client's rights by
shaming or embarrassing the client.
Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent
which adverse reaction?
A) Hypertension
B) Respiratory arrest
C) Tourette Syndrome
D) Retinal
pigmentation
Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other
options don't occur as a result of exceeding this dose.
How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a
client's delusional thoughts and hallucinations eliminated?
A) Several minutes
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
GUIDE 2021/2022 GRADED A+
A client with paranoid personality disorder is admitted to a psychiatric facility.
Which remark by the nurse would best establish rapport and encourage the
client to confide in the nurse?
A) "I get upset once in a while, too."
B) "I know just how you feel. I'd feel the same way in your situation."
C) "I worry, too, when I think people are talking about me."
D) "At times, it's normal not to trust anyone."
Sharing a benign, nonthreatening, personal fact or feeling helps the nurse
establish rapport and encourages the client to confide in the nurse. The
nurse can't know how the client feels. Telling the client otherwise, as in
option B, would justify the suspicions of a paranoid client; furthermore, the
client relies on the nurse to interpret reality. Option C is incorrect because it
focuses on the nurse's feelings, not the client's. Option D wouldn't help
establish rapport or encourage the client to confide in the nurse.
A client with paranoid schizophrenia repeatedly uses profanity during an activity
therapy session. Which response by the nurse would be most appropriate?
A) "Your behavior won't be tolerated. Go to your room immediately."
B) "You're just doing this to get back at me for making you come to therapy."
C) "Your cursing is interrupting the activity. Take time out in your room for 10
minutes."
D) "I'm disappointed in you. You can't control yourself even for a few minutes."
The nurse should set limits on client behavior to ensure a comfortable
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
, ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
environment for all clients. The nurse should accept hostile or quarrelsome
client outbursts within limits without becoming personally offended, as in
option A. Option B is incorrect because it implies that the client's actions
reflect feelings toward the staff instead of the client's own misery.
Judgmental remarks, such as option D, may decrease the client's self-
esteem.
The nurse is caring for a client with schizophrenia. Which of the following
outcomes is the least desirable?
A) The client spends more time by himself
B) The client doesn't engage in delusional thinking
C) The client doesn't harm himself or others
D) The client demonstrates ability to meet his own self-care needs
The client with schizophrenia is commonly socially isolated and withdrawn;
therefore, having the client spend more time by himself wouldn't be a
desirable outcome. Rather, a desirable outcome would specify that the client
spend more time with other clients and staff on the unit. Delusions are false
personal beliefs. Reducing or eliminating delusional thinking using talking
therapy and antipsychotic medications would be a desirable outcome.
Protecting the client and others from harm is a desirable client outcome
achieved by close observation, removing any dangerous objects, and
administering medications. Because the client with schizophrenia may have
difficulty meeting his or her own self-care needs, fostering the ability to
perform self-care independently is a desirable client outcome.
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
, ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
The nurse formulates a nursing diagnosis of Impaired verbal communication for
a client with schizotypal personality disorder. Based on this nursing diagnosis,
which nursing intervention is most appropriate?
A) Helping the client to participate in social
interactions B) Establishing a one-on-one
relationship with the client
C) Establishing alternative forms of communication
D) Allowing the client to decide when he wants to participate in verbal
communication with the nurse
By establishing a one-on-one relationship, the nurse helps the client learn how to interact with
people in new situations. The other options are appropriate but should take place only after
the nurse-client relationship is established.
Since admission 4 days ago, a client has refused to take a shower, stating,
"There are poison crystals hidden in the showerhead. They'll kill me if I take a
shower." Which nursing action is most appropriate?
A) Dismantling the showerhead and showing the client that there is nothing in it
B) Explaining that other clients are complaining about the client's body odor
C) Asking a security officer to assist in giving the client a shower
D) Accepting these fears and allowing the client to take a sponge bath
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
, ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
By acknowledging the client's fears, the nurse can arrange to meet the
client's hygiene needs in another way. Because these fears are real to the
client, providing a demonstration of reality (as in option A) wouldn't be
effective at this time. Options B and C would violate the client's rights by
shaming or embarrassing the client.
Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent
which adverse reaction?
A) Hypertension
B) Respiratory arrest
C) Tourette Syndrome
D) Retinal
pigmentation
Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other
options don't occur as a result of exceeding this dose.
How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a
client's delusional thoughts and hallucinations eliminated?
A) Several minutes
ATI MENTAL HEALTH PRACTICE- LATEST BEST
GUIDE 2021/2022 GRADED A+
