ATI RN
ATI Mental Health Proctored Exam 2019
1. A client with obsessive-compulsive disorder (OCD) spends hours each day washing her hands. Which intervention should the nurse implement to help the client reduce this behavior?
- A. Encourage the client to set a time limit for washing hands.
- B. Encourage the client to wash hands only when necessary.
- C. Encourage the client to use hand sanitizer instead of washing.
- D. Encourage the client to explore the reasons behind the hand washing.
Correct answer: A
Rationale: Setting a time limit for hand washing is an effective intervention in managing obsessive-compulsive disorder (OCD) symptoms. By establishing boundaries around the behavior, the client can gradually work towards reducing the excessive hand washing and regaining control over the compulsion. Choice B is not as effective because it does not address the underlying compulsion. Choice C may not be helpful as it may not satisfy the client's need for cleanliness and could reinforce the behavior. Choice D, while important in therapy, may not be the most immediate intervention needed to address the excessive hand washing behavior.
2. What should the nurse explain about ringworm?
- A. It is not contagious
- B. It is a sign of uncleanliness
- C. It is expected to resolve spontaneously
- D. It is spread by both direct and indirect contact
Correct answer: D
Rationale: Ringworm is a fungal infection that spreads through direct and indirect contact. Good hygiene practices can help prevent its spread.
3. When assessing a client diagnosed with anorexia nervosa, which of the following findings should the nurse expect? Select one that does not apply.
- A. Amenorrhea
- B. Lanugo
- C. Hypotension
- D. Hyperkalemia
Correct answer: D
Rationale: In a client diagnosed with anorexia nervosa, expected findings include amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa; instead, hypokalemia, which is low potassium levels, is more common. Hypokalemia can result from decreased intake of potassium-rich foods or excessive purging behaviors commonly seen in individuals with anorexia nervosa.
4. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?
- A. Encourage the client to discuss the voices.
- B. Instruct the client to listen to music to drown out the voices.
- C. Tell the client that the voices are not real.
- D. Distract the client from the voices.
Correct answer: A
Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia. Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.
5. A nurse is caring for a client who is receiving parenteral nutrition. Which of the following findings indicates the therapy is effective?
- A. Client has soft, formed bowel movements.
- B. Client’s mucous membranes are pink.
- C. Client reports ability to complete ADLs.
- D. Client’s blood glucose level is within the expected reference range.
Correct answer: D
Rationale: The correct answer is D because having a blood glucose level within the expected reference range indicates that parenteral nutrition is effectively meeting the client's nutritional needs. Choices A, B, and C are incorrect because soft, formed bowel movements, pink mucous membranes, and the ability to complete activities of daily living do not directly reflect the effectiveness of parenteral nutrition therapy.
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