a client with borderline personality disorder is admitted to the psychiatric unit which intervention should the nurse implement to promote the clients
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?

Correct answer: A

Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.

2. Which of the following statements should a healthcare professional recognize as true about defense mechanisms? Select the one that doesn't apply.

Correct answer: B

Rationale: Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity to relieve mild to moderate anxiety. They act as protective devices for the ego, not the id or superego. The id represents primal instincts, while the superego is associated with moral standards. Defense mechanisms help individuals cope with stressors by redirecting focus and are often unconscious and self-deceptive.

3. Which response by a 15-year-old demonstrates a common symptom observed in patients diagnosed with major depressive disorder?

Correct answer: D

Rationale: Sleep disturbances, such as early morning awakening, are common symptoms of major depressive disorder.

4. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?

Correct answer: C

Rationale: The nurse should recognize that the client is in the acceptance stage of grief based on the statement 'Yes, it was a difficult relationship, but I think I have learned from the experience.' In this statement, the client is acknowledging the difficulty of the relationship but also expressing personal growth and learning from the experience, indicating acceptance. Choices A, B, and D do not reflect the acceptance stage of grief. Choice A shows a sense of regret and a wish for things to have turned out differently. Choice B demonstrates lingering anger towards the ex-husband. Choice D suggests ongoing physical manifestations of grief like loss of appetite and weight loss, which are more indicative of earlier stages of grief.

5. A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?

Correct answer: D

Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.

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