which statement demonstrates a well structured attempt at limit setting
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2023

1. Which statement demonstrates a well-structured attempt at limit setting?

Correct answer: A

Rationale: Choice A, 'Hitting me when you are angry is unacceptable,' demonstrates a well-structured attempt at limit setting because it clearly defines the unacceptable behavior without ambiguity. This statement sets a clear boundary and clearly communicates the consequence for the behavior. In contrast, choices B, C, and D are less effective in setting limits as they are either vague expectations or commands without specific consequences for crossing the limit.

2. Upon admission, a client diagnosed with major depressive disorder needs the nurse to implement which of the following interventions first?

Correct answer: B

Rationale: The initial intervention the nurse should prioritize is to establish a trusting relationship with the client. Building trust is fundamental in fostering effective therapeutic communication and providing quality care. This foundational step lays the groundwork for further assessment, collaboration on care plans, and promoting treatment adherence. Administering medication or discussing compliance should come after the establishment of trust to ensure the client feels supported and understood.

3. What information should the nurse provide in patient education for a patient prescribed sertraline for major depressive disorder?

Correct answer: B

Rationale: Patients prescribed sertraline for major depressive disorder should be educated that it may take several weeks before experiencing the full therapeutic effects of the medication. This delay in onset of action is common with antidepressants like sertraline, and patients need to be aware of this to manage their expectations and continue with the treatment regimen. It's important for the patient to understand that consistent adherence to the prescribed dosage is crucial, even if the full effects are not immediately apparent. Choices A, C, and D are incorrect because taking the medication with food, avoiding grapefruit, and regular blood tests are not specific education points related to the expected timeframe for therapeutic effects of sertraline.

4. When preparing a teaching plan for a client with generalized anxiety disorder, which information should a healthcare professional include?

Correct answer: C

Rationale: The correct answer is C: Practicing relaxation techniques. This is a crucial aspect of managing generalized anxiety disorder. Techniques like deep breathing, progressive muscle relaxation, and mindfulness can effectively reduce anxiety levels and promote calmness. These techniques provide valuable coping mechanisms to help individuals with generalized anxiety disorder deal with stress and anxiety.\nChoice A, avoiding caffeine and other stimulants, can be beneficial but is not as central to managing generalized anxiety disorder as practicing relaxation techniques.\nChoice B, engaging in regular physical activity, is also helpful for managing anxiety, but relaxation techniques are more specific and targeted for addressing symptoms of generalized anxiety disorder.\nChoice D, keeping a journal of anxiety triggers, may be a useful strategy to identify triggers but does not directly address the immediate management of anxiety symptoms, unlike practicing relaxation techniques.

5. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response?

Correct answer: B

Rationale: The correct answer is B: 'How you reacted to past experiences influences how you feel now.' This response is appropriate because past experiences can shape an individual's current response to stress. It acknowledges the impact of learned patterns and coping mechanisms on one's current adaptation to stressors. Choice A is incorrect because genetics can play a role in temperament to some extent. Choice C is incorrect because while physical health can contribute to stress management, it is not the sole determinant of stress levels. Choice D is incorrect as stress is not always avoidable, but coping mechanisms can help manage and reduce its impact.

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