ATI RN MENTAL HEALTH 2019 WITH NGN
100% PASS WITH RATIONALES LATEST UPDATES
QUESTION & ANSWERS
WITH RATIONALES
A nurse is caring for a group of patients. For which of the following situations should the nurse
complete an incident report? - ANS - 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? - ANS - 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 patients
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 - ANS - 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 - ANS - 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 - ANS - 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 - ANS - 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 - ANS - 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? - ANS - 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
b. Extended periods of depression
c. Deficits in intellectual functioning
d. Aggression towards animals - ANS - d. Aggression toward animals
Rationale: The nurse should identify that aggression toward people and animals is an expected
characteristic of a child who has conduct disorder
a. The nurse should identify that lack of remorse is an expected characteristic of a child who
has conduct disorder
b. The nurse should identify that a child who has bipolar disorder is likely to have extended
periods of depression. This is not an expected characteristic of a child who has conduct disorder c.
The nurse should identify that a child who has intellectual deficit disorder exhibits deficits in
intellectual functioning, such as reasoning, abstract thinking, and academic ability. A deficit in
intellectual functioning is not an expected characteristic of a child who has conduct disorder
A nurse in a mental health clinic is planning care for a client who has a new prescription for
Olanzapine. Which of the following interventions should the nurse identify as the priority? - ANS -
Instruct the client to avoid driving during initial therapy
Rationale: The greatest risk to the patient is injury resulting from drowsiness or dizziness.
Therefore, the nurse's priority intervention is to instruct the patient to avoid activities that require
mental alertness during initial medication therapy
A nurse is caring for a patient who has a history of substance use disorder and was involuntarily
admitted to a mental health facility. When the nurse attempts to administer oral Lorazepam, the
patient refuses to take the medication and becomes physically aggressive. Which of the following
actions should the nurse take?
a. Do not administer the Lorazepam
b. Request a prescription for IV lorazepam
c. Request that another nurse attempt to administer the lorazepam
d. Place the lorazepam in the patient's food - ANS - a. Do not administer the Lorazepam
Rationale: Patients who are in a facility due to an involuntary admission retain the right to refuse
treatment. Therefore, the nurse should hold the medication and document the patient's refusal
b. Requesting a prescription for and administering IV lorazepam violates the patient's right to
refuse treatment
b. Requesting that another nurse administer the lorazepam violates the patient's right to refuse
treatment
100% PASS WITH RATIONALES LATEST UPDATES
QUESTION & ANSWERS
WITH RATIONALES
A nurse is caring for a group of patients. For which of the following situations should the nurse
complete an incident report? - ANS - 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? - ANS - 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 patients
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 - ANS - 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 - ANS - 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 - ANS - 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 - ANS - 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 - ANS - 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? - ANS - 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
b. Extended periods of depression
c. Deficits in intellectual functioning
d. Aggression towards animals - ANS - d. Aggression toward animals
Rationale: The nurse should identify that aggression toward people and animals is an expected
characteristic of a child who has conduct disorder
a. The nurse should identify that lack of remorse is an expected characteristic of a child who
has conduct disorder
b. The nurse should identify that a child who has bipolar disorder is likely to have extended
periods of depression. This is not an expected characteristic of a child who has conduct disorder c.
The nurse should identify that a child who has intellectual deficit disorder exhibits deficits in
intellectual functioning, such as reasoning, abstract thinking, and academic ability. A deficit in
intellectual functioning is not an expected characteristic of a child who has conduct disorder
A nurse in a mental health clinic is planning care for a client who has a new prescription for
Olanzapine. Which of the following interventions should the nurse identify as the priority? - ANS -
Instruct the client to avoid driving during initial therapy
Rationale: The greatest risk to the patient is injury resulting from drowsiness or dizziness.
Therefore, the nurse's priority intervention is to instruct the patient to avoid activities that require
mental alertness during initial medication therapy
A nurse is caring for a patient who has a history of substance use disorder and was involuntarily
admitted to a mental health facility. When the nurse attempts to administer oral Lorazepam, the
patient refuses to take the medication and becomes physically aggressive. Which of the following
actions should the nurse take?
a. Do not administer the Lorazepam
b. Request a prescription for IV lorazepam
c. Request that another nurse attempt to administer the lorazepam
d. Place the lorazepam in the patient's food - ANS - a. Do not administer the Lorazepam
Rationale: Patients who are in a facility due to an involuntary admission retain the right to refuse
treatment. Therefore, the nurse should hold the medication and document the patient's refusal
b. Requesting a prescription for and administering IV lorazepam violates the patient's right to
refuse treatment
b. Requesting that another nurse administer the lorazepam violates the patient's right to refuse
treatment
