ATI RN MENTAL HEALTH 2019 WITH NGN 100% PASS WITH RATIONALES

ATI RN MENTAL HEALTH 2019

WITH NGN

A nurse is caring for a group of patients. For which of the following situations should the

nurse complete an incident report? CORRECT ANSWER- A client was administered

one-half of the prescribed dose of medication

Rationale: An incident report is a recording of any occurrence that does not meet the

standard of care. The nurse should report medication errors using the facility's incident

or occurrence form.

A nurse is caring for a group of patients. Which of the following findings is the nurse

required to report? CORRECT ANSWER- A client who has borderline personality

disorder threatened to harm their roommate

Rationale: Signs and symptoms of BPD include interpersonal relationships

accompanied by threats and other-directed violence. While it is important for the nurse

to maintain the patient’s confidentiality, when another individual might be in danger, the

nurse is required by law to report it to authorities.

A nurse is caring for a patient who has borderline personality disorder. Which of the

following goals is the priority when planning care for this patient?

a. The patient will take the prescribed medications as scheduled

b. The patient will express feelings of frustration

c. The patient will refrain from self-mutilation

d. The patient will participate in group therapy CORRECT ANSWER- c. The client will

refrain from self-mutilation

Rationale: The greatest risk to the patient is injury to self and others. Therefore, the

priority goal is for the patient to refrain from self-mutilation

a. Taking prescribed medications as scheduled to maintain therapeutic blood levels is

an important goal. However, this is not the priority goal

b. Expressing feelings of frustration to acknowledge these feelings is an important goal.

However, this is not the priority goal

d. Participating in group therapy as part of the treatment plan is an important goal.

However, this is not the priority goal

A nurse is discussing the home care of a patient who has advanced Alzheimer's

disease. The patient's caregiver is planning to go out of town for several days. Which of

the following resources should the nurse recommended to the caregiver?

a. Respite care

b. Partial hospitalization

c. Adult day care program

d. Geropsychiatric unit CORRECT ANSWER- a. Respite care

Rationale: Respite care programs allow the patient to stay in a nursing facility for a set

number of days, allowing the caregivers to go on vacation or have some time to

themselves

b. Partial hospitalization provides services for several hours during the day, but they are

not designed to offer 24-hr care. A patient with advanced Alzheimer's disease is unable

to safely remain at home unattended

c. Adult day care programs can provide services throughout the day to patient's with

Alzheimer's disease, allowing the caregiver the ability to work or have a break. The

patient's return home in the evening. A patient who has advanced Alzheimer's disease

is unable to safely remain at home unattended.

d. A geropsychiatric unit provides care for patients requiring acute psychiatric services

due to sudden mental status changes, psychosis, or other mental health services.

These services are ideal for patients who are at risk of harming themselves or others

A nurse is caring for an older adult patient who has dementia and has wandered into the

day room looking for their deceased partner. Which of the following actions should the

nurse take?

a. Move the patient to a room near the nurses' station

b. Limit visitors until the patient is oriented to the environment

c. Tell the patient their partner is deceased

d. Talk with the patient about activities they enjoyed with their partner CORRECT

ANSWER- Talk with the patient about activities they enjoyed with their partner

Rationale:

Talking about positive experiences can help distract the patient from their disorientation

a. When caring for a patient with dementia, avoid placing them in unfamiliar settings

when possible.

b. Family members should be encouraged to interact with the patient regardless of the

patient's state of dementia

c. Confrontation should not be used for a disoriented patient

A nurse is admitting a patient with schizophrenia to an acute care setting. When the

nurse questions the patient regarding their admission, the client states, "I'm red, in the

head, and I'm going to bed!" The nurse should document the client's speech pattern as

which of the following?

a. Clang association

b. Word salad

c. Neologism

d. Echolalia CORRECT ANSWER- a. Clang association

Rationale: The nurse should document that the patients speech uses clang associations

which often rhyme or contain a string of words that can have a similar sound

b. In word salad, words are completely meaningless and disorganized.

c. Neologism consists of words that are made up by the patient

d. In echolalia, the patient repeats the words of another person

A nurse is assessing a patient who has schizophrenia. Which of the following findings

should the nurse document as a negative symptom of this disorder?

a. Delusions

b. Neologisms

c. Anhedonia

d. Echopraxia CORRECT ANSWER- Anhedonia

Rationale:

Positive symptoms of schizophrenia usually appear suddenly and are alteration in

behavior, perception, speech, and thought. Delusions, inability to think abstractly,

neologisms (made up words), echolalia (repeating of someone else's words, motor

agitation, and echopraxia (mimicking someone else's movements) are all positive

symptoms of schizophrenia.

Negative symptoms of schizophrenia affect a person's ability to interact with others and

are less dominant than positive symptoms. Negative symptoms develop over time.

Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia

(inability to enjoy otherwise pleasurable activities), and thought blocking (inability to

think, speak, or move in response to outside stimuli)

A nurse is delegating patient care tasks to a licensed practical nurse (LPN) and an

assistive personnel. Which of the following tasks should the nurse assign to the LPN?

CORRECT ANSWER- Change the dressing of a client who has borderline personality

disorder and superficial self-inflicted wounds

Rationale: A patient who has borderline personality disorder is at risk for self-mutilation

such as cutting, self-inflicted wounds, scratching or picking at wounds. It is within the

LPNs scope of practice to change the dressing, cleanse the wound, and collect data

regarding the healing of the wound.

A nurse is assessing a school-age child who has conduct disorder. Which of the

following characteristics should the nurse expect the child to demonstrate?

a. Feelings of remorse