ATI RN
ATI Mental Health Practice B
1. A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement first?
- A. Ask the client to describe the content of the hallucinations.
- B. Instruct the client to ignore the hallucinations.
- C. Administer prescribed antipsychotic medication.
- D. Engage the client in reality-based activities.
Correct answer: A
Rationale: The initial intervention for a client experiencing auditory hallucinations, especially in schizophrenia, is to assess the content of the hallucinations. By asking the client to describe the hallucinations, the nurse can determine if they are command hallucinations that might pose a risk. This assessment is crucial in guiding further appropriate interventions to ensure the client's safety and well-being. Instructing the client to ignore the hallucinations (Choice B) may not be effective, as the hallucinations are real to the client. Administering antipsychotic medication (Choice C) may be necessary but should come after assessing the situation. Engaging the client in reality-based activities (Choice D) is important but not the first priority when dealing with auditory hallucinations.
2. Which of the following symptoms should a healthcare professional expect to assess in a client diagnosed with major depressive disorder? Select one that does not apply.
- A. Loss of interest or pleasure
- B. Decreased ability to concentrate
- C. Significant weight loss or gain
- D. Increased energy
Correct answer: D
Rationale: Symptoms of major depressive disorder include a loss of interest or pleasure, decreased ability to concentrate, significant weight loss or gain, and feelings of worthlessness or excessive guilt. Increased energy is not typically associated with major depressive disorder; instead, fatigue is more common. Clients with major depressive disorder often experience a lack of energy, motivation, or enthusiasm, leading to feelings of lethargy and fatigue. Therefore, increased energy is an atypical symptom in major depressive disorder, making it the correct answer.
3. A client with borderline personality disorder is receiving care. Which of the following interventions should be included in the plan of care?
- A. Set clear and consistent boundaries
- B. Encourage independence
- C. Avoid discussing the client's feelings
- D. Use a firm, authoritative approach
Correct answer: B
Rationale: When caring for a client with borderline personality disorder, it is essential to encourage independence rather than dependency. This helps promote autonomy and self-reliance, which are important aspects of treatment. Setting clear and consistent boundaries is also crucial, as it provides structure and predictability. Avoiding discussing the client's feelings is not recommended, as addressing emotions and promoting emotional awareness is a key part of therapy. Using a firm, authoritative approach may not be the most effective strategy as it can lead to power struggles and conflicts in individuals with borderline personality disorder.
4. A nurse is providing education to a client diagnosed with generalized anxiety disorder (GAD). Which of the following statements by the client indicates a need for further teaching? Select one that does not apply.
- A. I should avoid caffeine because it can increase my anxiety.
- B. I can stop taking my medication once I feel better.
- C. Practicing deep breathing exercises can help reduce my anxiety.
- D. I should gradually face situations that cause me anxiety.
Correct answer: B
Rationale: Statements indicating a need for further teaching include stopping medication once feeling better and believing that medication will always be needed. Medication should be continued as prescribed, and the need for it should be regularly re-evaluated by a healthcare provider.
5. A client diagnosed with borderline personality disorder tells the nurse, 'You are the only one who understands me. The other nurses don't care about me.' Which of the following responses should the nurse make?
- A. Why do you feel that way?
- B. The other nurses care about you too.
- C. You shouldn't say things like that.
- D. I think you are overreacting.
Correct answer: B
Rationale: The correct response is to acknowledge the client's feelings and provide support while also emphasizing that all staff members care about the client's well-being. Choice A does not acknowledge the client's emotions and may come across as dismissive. Choice C invalidates the client's feelings and may make the client feel misunderstood. Choice D minimizes the client's emotions, which can lead to a breakdown in therapeutic communication. Therefore, option B is the most appropriate response as it validates the client's feelings while reinforcing the idea that the entire healthcare team is supportive.
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