a client states i am the only one who can hear voices which is the nurses best response
Logo

Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

Correct answer: A

Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.

2. Which of the following would be the most appropriate intervention for a patient experiencing severe anxiety?

Correct answer: C

Rationale: During a severe anxiety episode, it's crucial to stay with the patient and create a quiet environment. This approach helps reduce anxiety by providing a sense of safety and support. Encouraging the patient to talk about their feelings may not be effective during an acute episode of severe anxiety. Using a firm, authoritative approach can escalate the situation and worsen the anxiety. Suggesting distractions like watching TV may not address the root cause of the anxiety or provide the necessary support.

3. A healthcare provider is providing care for a patient with attention-deficit/hyperactivity disorder (ADHD). Which therapeutic intervention is most effective for this condition?

Correct answer: B

Rationale: Cognitive-behavioral therapy (CBT) is the most effective therapeutic intervention for managing ADHD symptoms. CBT helps individuals with ADHD develop coping strategies, improve focus, organization, and time management skills, and address behavioral challenges effectively. Group therapy might not provide the specific skills training needed for ADHD management. Psychoanalysis focuses on exploring deeper unconscious processes and may not be as practical for addressing ADHD symptoms. Family therapy can be beneficial for family dynamics but may not directly target individual ADHD symptoms as effectively as CBT.

4. A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms shouldn't the nurse expect to observe during withdrawal?

Correct answer: D

Rationale: During alcohol withdrawal, the nurse should expect to observe symptoms such as tremors, hallucinations, and diaphoresis. Seizures may also occur during severe withdrawal. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia (an increased heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the sympathetic nervous system.

5. Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

Correct answer: B

Rationale: Checking for congruence between verbal and nonverbal communication helps validate the patient's response.

Similar Questions

A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings should the healthcare professional expect? Select one that doesn't apply.
Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his 'nice' mom, that he loves school, and gets above-average grades. The strongest explanation of this response is:
A client with schizophrenia is prescribed risperidone. Which statement by the client indicates a need for further teaching?
Which drug group requires nursing assessment for the development of abnormal movement disorders in individuals taking therapeutic dosages?
A client diagnosed with generalized anxiety disorder (GAD) states, 'I just can't stop worrying about everything.' Which nursing diagnosis is most appropriate for this client?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses