ATI Mental Health Final Quiz (aka Quiz 3)
written by
Quikrevision
www.stuvia.com
,1. A nurse is planning care for a client who has borderline personality disorder who
self-mutilates. Which of the following test approaches should the nurse plan to take?
a. Restrict participation in group therapy sessions.
The nurse should encourage the client who has borderline personality disorder to
participate in group therapy sessions to encourage appropriate interaction with
other clients.
b.Establish consequences for self-mutilation.
The nurse should respond to self-mutilation with a neutral affect and encourage
the client to write down feelings that occurred leading up to the incident.
c. Maintain close observation of the client.
Clients who have borderline personality disorder are at risk for self-harm
during times of increased anxiety. Maintaining close observation reduces
the client's risk of injury.
d.Provide an unstructured environment.
Providing an unstructured environment for a client who has borderline personality
disorder is not an effective treatment approach because it does not provide a
safe environment to protect the client from impulsive and self-injurious behavior.
2. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the
following findings should the nurse expect?
a. The client requires assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still
have the ability to eat without assistance. Clients who have Alzheimer’s disease
maintain this ability until Stage 7.
b.The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease
to have difficulty performing complex tasks, such as managing personal
finances.
c.The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be
able to use the toilet independently. Clients who have Alzheimer’s disease
maintain continence until Stage 6.
d. The client is able to identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until Stag
6.
3. A nurse is caring for a client who reports that the television set in the room is really a
two-way radio and states, "voices are coming from the TV and everything we say in the
room is being recorded." Which of the following responses should the nurse make?
a. "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This
response can promote a defensive client response and interfere with the
, development of trust in the nurse-client relationship.
b."Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to
determine if there is a safety risk. The nurse should also avoid validating that the
voices are real, which promotes the client’s beliefs about the delusion.
c. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic
manner. By acknowledging to the client that the delusion must be frightening, the
nurse promotes the nurse- client relationship.
d."Why do you think the TV is a two-way radio?"
, The nurse should avoid asking the client a "why" question, which promotes a
defensive client response.
4. A nurse is planning care for a newly admitted client who has bipolar disorder and is
experiencing acute mania. Which of the following client goals should the nurse identify
as the priority?
a. Practicing problem-solving skills
The nurse should encourage the client to practice problem-solving skills during
the continuation phase of treatment; however, there is another intervention that is
the priority during the acute phase of bipolar disorder.
b.Understanding of medication regimen
The nurse should ensure that the client understands the medication regimen
during the continuation phase of treatment; however, there is another
intervention that is the priority during the acute phase of bipolar disorder.
c. Identifying indications of relapse
The nurse should teach the client to recognize indications of relapse during the
continuation phase of treatment; however, there is another intervention that is the
priority during the acute phase of bipolar disorder.
d. Maintaining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s
manic episode. The nurse should consider Maslow’s hierarchy of needs, which
includes five levels of priority when planning care for this client. The first level
consists of physiological needs; the second level consists of safety and security
needs; the third level consists of love and belonging needs; the fourth level
consists of personal achievement and self-esteem needs; and the fifth level
consists of achieving full potential and the ability to problem solve and cope with
life situations. When applying Maslow’s hierarchy of needs priority-setting
framework the nurse should review physiological needs first. The nurse should
then address the client’s needs by following the remaining four hierarchical
levels. It is important, however, for the nurse to consider all contributing client
factors, as higher levels of the pyramid can compete with those at the lower
levels, depending on the specific client situation. The fourth level of Maslow’s
hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling
self-esteem needs.
5. A nurse is preparing to administer benzodiazepine to a client with Generalized
Anxiety Disorder. The nurse should tell the client to expect with of the following
adverse reactions?
a. Tinnitus
Tinnitus is not an adverse effect of benzodiazepines.
b.Bradycardia
Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines.
c. Halitosis
Halitosis is not an adverse effect of benzodiazepines.
d. Sedation
written by
Quikrevision
www.stuvia.com
,1. A nurse is planning care for a client who has borderline personality disorder who
self-mutilates. Which of the following test approaches should the nurse plan to take?
a. Restrict participation in group therapy sessions.
The nurse should encourage the client who has borderline personality disorder to
participate in group therapy sessions to encourage appropriate interaction with
other clients.
b.Establish consequences for self-mutilation.
The nurse should respond to self-mutilation with a neutral affect and encourage
the client to write down feelings that occurred leading up to the incident.
c. Maintain close observation of the client.
Clients who have borderline personality disorder are at risk for self-harm
during times of increased anxiety. Maintaining close observation reduces
the client's risk of injury.
d.Provide an unstructured environment.
Providing an unstructured environment for a client who has borderline personality
disorder is not an effective treatment approach because it does not provide a
safe environment to protect the client from impulsive and self-injurious behavior.
2. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the
following findings should the nurse expect?
a. The client requires assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still
have the ability to eat without assistance. Clients who have Alzheimer’s disease
maintain this ability until Stage 7.
b.The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease
to have difficulty performing complex tasks, such as managing personal
finances.
c.The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be
able to use the toilet independently. Clients who have Alzheimer’s disease
maintain continence until Stage 6.
d. The client is able to identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until Stag
6.
3. A nurse is caring for a client who reports that the television set in the room is really a
two-way radio and states, "voices are coming from the TV and everything we say in the
room is being recorded." Which of the following responses should the nurse make?
a. "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This
response can promote a defensive client response and interfere with the
, development of trust in the nurse-client relationship.
b."Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to
determine if there is a safety risk. The nurse should also avoid validating that the
voices are real, which promotes the client’s beliefs about the delusion.
c. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic
manner. By acknowledging to the client that the delusion must be frightening, the
nurse promotes the nurse- client relationship.
d."Why do you think the TV is a two-way radio?"
, The nurse should avoid asking the client a "why" question, which promotes a
defensive client response.
4. A nurse is planning care for a newly admitted client who has bipolar disorder and is
experiencing acute mania. Which of the following client goals should the nurse identify
as the priority?
a. Practicing problem-solving skills
The nurse should encourage the client to practice problem-solving skills during
the continuation phase of treatment; however, there is another intervention that is
the priority during the acute phase of bipolar disorder.
b.Understanding of medication regimen
The nurse should ensure that the client understands the medication regimen
during the continuation phase of treatment; however, there is another
intervention that is the priority during the acute phase of bipolar disorder.
c. Identifying indications of relapse
The nurse should teach the client to recognize indications of relapse during the
continuation phase of treatment; however, there is another intervention that is the
priority during the acute phase of bipolar disorder.
d. Maintaining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s
manic episode. The nurse should consider Maslow’s hierarchy of needs, which
includes five levels of priority when planning care for this client. The first level
consists of physiological needs; the second level consists of safety and security
needs; the third level consists of love and belonging needs; the fourth level
consists of personal achievement and self-esteem needs; and the fifth level
consists of achieving full potential and the ability to problem solve and cope with
life situations. When applying Maslow’s hierarchy of needs priority-setting
framework the nurse should review physiological needs first. The nurse should
then address the client’s needs by following the remaining four hierarchical
levels. It is important, however, for the nurse to consider all contributing client
factors, as higher levels of the pyramid can compete with those at the lower
levels, depending on the specific client situation. The fourth level of Maslow’s
hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling
self-esteem needs.
5. A nurse is preparing to administer benzodiazepine to a client with Generalized
Anxiety Disorder. The nurse should tell the client to expect with of the following
adverse reactions?
a. Tinnitus
Tinnitus is not an adverse effect of benzodiazepines.
b.Bradycardia
Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines.
c. Halitosis
Halitosis is not an adverse effect of benzodiazepines.
d. Sedation
