a client tells a nurse dont tell anyone but i hid a sharp knife under my mattress in order to protect myself from my roommate who is always threatenin
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Nursing Elites

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ATI Mental Health Proctored Exam 2019

1. A client tells a nurse, 'Don’t tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?

Correct answer: C

Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.

2. A patient with generalized anxiety disorder (GAD) is prescribed buspirone. Which statement by the patient indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A. Buspirone is not meant to be taken on an as-needed basis. It should be taken consistently every day to achieve the desired therapeutic effect. Choice B is correct as it accurately reflects that buspirone may take a few weeks to reach its full effect. Choice C is also correct as buspirone indeed has a lower risk of dependency compared to benzodiazepines. Choice D is correct because taking buspirone consistently every day is the appropriate way to use this medication.

3. What is the primary goal of eye movement desensitization and reprocessing (EMDR) when treating a patient with posttraumatic stress disorder (PTSD)?

Correct answer: A

Rationale: The primary goal of eye movement desensitization and reprocessing (EMDR) in treating patients with posttraumatic stress disorder (PTSD) is to help them confront and process traumatic memories. EMDR uses bilateral stimulation to facilitate the processing of distressing memories, leading to their desensitization and reprocessing, ultimately reducing PTSD symptoms.

4. When developing a care plan for a patient with borderline personality disorder, which intervention should be included to address self-harm behaviors?

Correct answer: D

Rationale: Developing a safety plan with the patient is crucial when addressing self-harm behaviors in individuals with borderline personality disorder. This intervention helps outline steps to take during a crisis, identifies triggers, and provides strategies to prevent self-harm incidents. It involves collaboratively creating a plan between the patient and the healthcare team to ensure a structured and supportive approach to managing potentially dangerous situations.

5. What principle about patient communication should guide a nurse's fear of 'saying the wrong thing' to a patient?

Correct answer: A

Rationale: Effective patient communication is guided by the principle that patients value genuine acceptance, respect, and concern from their caregivers. This approach helps to build trust and fosters effective communication, enhancing the nurse-patient relationship. Choice B is incorrect because patients value both talking and listening in effective communication. Choice C is incorrect because a nurse should always consider the impact of their words on the patient, regardless of the patient's history. Choice D is incorrect as it generalizes about people with mental illness and forgiveness, which is not directly relevant to patient communication.

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