Unit 5 Exam
A nurse is interviewing a client during admission to a mental health unit. Which of the following strategies should the nurse use? Select all that apply. a. Use a private, quiet space with adequate lighting. b. Stand or sit at the client's level to conduct the interview. c. Instruct the family that they must leave during the interview. d. Obtain a detailed medication history. e. Use touch frequently so that the client becomes accustomed to it.
Correct: a, b, d Response Feedback: ATI Chapter 1, p. 5 A private quite space with adequate lighting, standing or sitting at the client's level to conduct the interview, and obtaining a detailed medical history are all strategies that should be used.
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions? a. Denial b. Displacement c. Projection d. Undoing
Correct: a. Denial Response Feedback: ATI Chapter 4, p. 20-21 Denial is pretending the truth is not reality to manage unpleasant, anxiety-causing thoughts or feelings.
A nurse is planning care for the termination phase of a nurse- client relationship. Which of the following actions should the nurse include in the plan of care? a. Discuss ways for client to incorporate healthy behaviors into life. b. Explore and deal with resistance and other defense mechanisms. c. Establish boundaries. d. Develop goals.
Correct: a. Discuss ways for client to incorporate healthy behaviors into life Response Feedback: ATI Chapter 5, p. 27 Discussing ways for the client to incorporate new healthy behaviors into life occurs in the termination phase.
A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? a. Explore the client's issues and needs. b. Overcome resistance behaviors. c. Review the client's progress toward personal objectives. d. Discuss ways for the client to incorporate new healthy behaviors into life.
Correct: a. Explore the client's issues and needs Response Feedback: ATI Chapter 5, p. 27 In the orientation phase, nurses explore the client's issues and needs.
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following screening tools could be used to assess for cognitive deficits? a. Mini Mental Status Examination (MMSE) b. Brief Patient Health Questionnaire (Brief PHQ) c. Abnormal Involuntary Movements Scale (AIMS) d. Scale for Assessment of Negative Symptoms (SANS)
Correct: a. MMSE Response Feedback: ATI Chapter 1, p. 4 The MMSE is used to objectively assess a client's cognitive status.
A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take? a. Maintain a nonjudgmental attitude. b. Avoid displaying an emotional response. c. Offer sympathetic support. d. Verbalize disapproval of the client's substance abuse.
Correct: a. Maintain a nonjudgmental attitude Response Feedback: ATI Chapter 5, p. 25 Clients should feel cared for and accepted by the staff and others in a therapeutic milieu.The nurse should portray genuineness, empathy, and a positive regard toward the client.
A nurse is admitting a homeless client to the mental health unit. The client is unkempt, dirty, and malnourished. Which of the following therapeutic strategies should the nurse focus on first? a. Offer assistance with self-care tasks. b. Assist the client to participate in an art activity. c. Provide teaching to the client about medications. d. Encourage the client to use stress management techniques.
Correct: a. Offer assistance with self-care tasks Response Feedback: ATI Chapter 1, p. 5 According to Maslow's hierarchy of needs, basic needs such as food, shelter, and hygiene are physiological needs that should be addressed first.
A nurse is providing education to a group of parents and teenagers on preventing suicide. Which of the following levels of prevention is this an example of? a. Primary prevention. b. Secondary prevention. c. Tertiary prevention. d. Quarternary prevention.
Correct: a. Primary prevention Response Feedback: ATI Chapter 6, p. 32 Primary prevention promotes health and prevent mental illness from occurring.
A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints? a. Self-destructive behavior despite alternative interventions. b. Coercion to take prescribed medications. c. Discipline for throwing objects at staff. d. Punishment for verbally abusing other clients.
Correct: a. Self-destructive behavior despite alternative interventions Response Feedback: ATI Chapter 2, pp. 10-11 Mechanical restraints should only be used to prevent a client from harming self or others, and should only be used when less restrictive measures are not effective.
A nurse is caring for a client who is dying. Which of the following interventions should the nurse use to support the client and family in the grieving process? Select all that apply. a. Explain to the family that the client will not be able to hear what is said. b. Allow family members to participate in care of the client. c. Provide privacy for the client and family. d. Answer call lights promptly. e. Educate the family on what to expect as the client moves closer to death.
Correct: b, c, d, e Response Feedback: ATI Chapter 27, p. 163 It is widely accepted that hearing is the last of the senses that is lost, so family should be encouraged to talk to their loved one.
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make? a. "Most clients with anxiety issues benefit from lying down." b. "Come with me to an area where we can talk without interruption." c. "Providers usually recommend relaxation exercises for clients who are as upset as you are." d. "An antianxiety pill works best for situations like this."
Correct: b. "Come with me to an area where we can talk without interruption." Response Feedback: ATI Chapter 4, p. 21 With this response, the nurse illustrates the therapeutic communication technique of offering herself. She demonstrates empathy by respecting the client's privacy and showing her willingness to listen.
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make? a. "We will call your family in time for them to get here." b. "I wonder if you are fearful of dying alone." c. "I will make sure a staff member is in your room at all times." d. "I will tell your family of your concern so that they can be here."
Correct: b. "I wonder if you are fearful of dying alone." Response Feedback: ATI Chapter 7, p.163 The nurse is verbalizing the client's implied concerns and seeks to validate if this is the client's concern.
A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make? a. "Do you think your anxiety is worse than everyone else's?" b. "Tell me what has been happening lately." c. "It doesn't appear as though you are feeling anxious." d. "I think you should see a therapist."
Correct: b. "Tell me what has been happening lately." Response Feedback: ATI Chapter 3, p. 17; Varcarolis, Chapter 8 p. 98-99 "Tell me what has been happening lately" offers a general lead that allows the client to take direction in the discussion and indicates that the nurse is interested in what comes next.
A nurse and client are in the working phase of the therapeutic relationship. The client states to the nurse, "I really enjoy our time together; you are a great friend." Which of the following statements demonstrates an appropriate response from the nurse? a. "I enjoy our time together too; let's get together for coffee after our sessions." b. "You are making good progress; let's continue to focus on your goals and how you will achieve them." c. "I hope that we can continue our friendship once our sessions have ended." d. "Thanks, but I am not your friend."
Correct: b. "You are making good progress; let's continue to focus on your goals and how you will achieve them." Response Feedback: ATI p. 26 "You are making good progress; let's continue to focus on your goals and how you will achieve them" reminds the client of the boundaries of the relationship.
A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse? a. "Tell me about the concerns that you have regarding your relationship." b. "You should try to see your partner's point of view before your own." c. "We could develop a plan for how to talk about this with your partner." d. "Relationship difficulties are stressful and require effort to resolve."
Correct: b. "You should try to see your partner's point of view before your own." Response Feedback: ATI Chapter 3, p. 17; Varcarolis, Chapter 8 p. 98-99 This statement gives advice, which is nontherapeutic.
A charge nurse is admitting a client who is in the manic phase of a bipolar disorder. The client is irritable, restless, agitated, and is talking rapidly and constantly. Which of the following room assignments should the nurse give the client? a. A semi-private room across from the day room. b. A private room in a quiet location on the unit. c. A private room across from the exercise room. d. A semi-private room across from the snack area.
Correct: b. A private room in a quiet location on the unit Response Feedback: ATI Chapter 5, p. 26 A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.
A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients would seclusion be contraindicated? a. A school-age client who attempts to repeatedly bite staff. b. An adult client experiencing a panic attack. c. An adolescent client who throws objects at other clients. d. An older adult client who is manic and crying due to overstimulation.
Correct: b. An adult client experiencing a panic attack Response Feedback: ATI Chapter 2, pp. 10-11 Seclusion should not be used for clients who are extremely physically or mentally unstable or cannot tolerate the decreased stimulation of a seclusion room.
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving? a. Bargaining b. Denial c. Depression d. Anger
Correct: b. Denial Response Feedback: ATI Chapter 27, p. 162 Denial is where the client has difficulty believing a terminal diagnosis or loss.
A nurse is caring for a client who sustained a minor injury during a street fight in which two of the clients' friends were stabbed. The client tells the nurse that he doesn't remember anything that happened after he and his friends first saw the suspects in the stabbing. The nurse should identify the client is exhibiting which of the following defense mechanisms? a. Suppression b. Undoing c. Projection d. Dissociation
Correct: b. Dissociation Response Feedback: ATI Chapter 4, p. 20-21 Dissociation is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment.
A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship? a. Determine the reason the client sought care. b. Encourage the client to problem-solve. c. Summarize goals and achievements. d. Review the client's demographic information.
Correct: b. Encourage the client to problem solve Response Feedback: ATI Chapter 5, p. 27 Problem solving occurs in the working phase.
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? a. Invasion of privacy. b. False imprisonment. c. Assault. d. Battery.
Correct: b. False imprisonment Response Feedback: ATI Chapter 2, p. 11 False imprisonment is the confining of a client to a specific area if the reason is for convenience of staff.
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? a. Hypotension b. Frequent infections c. Increased energy d. Increased cognitive awareness
Correct: b. Frequent infections Response Feedback: ATI Chapter 9, p. 47-48 The nurse should expect to find the client with a decreased immune response, which leads to viral or bacterial infections in response to chronic stress.
A nurse is assessing a client on a mental health unit and finds that the client is drowsy and falls asleep frequently during the assessment. Which of the following terms would the nurse use to describe the client's level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose
Correct: b. Lethargic Response Feedback: ATI Chapter 1, p. 3 Lethargic: Client is able to open eyes and respond but is drowsy and falls asleep easily.
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? a. Conversion b. Projection c. Undoing d. Regression
Correct: b. Projection Response Feedback: ATI Chapter 4, p. 20-21 A person unconsciously rejects emotionally unacceptable personal features and attributes them to other people, objects, or situations through projection. Projection is the hallmark of blaming.
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time? a. Suggest that the client rest in bed. b. Remain with the client. c. Medicate the client with a sedative. d. Have the client join a therapy group.
Correct: b. Remain with the client Response Feedback: ATI Chapter 4, p. 21 The nurse should not leave a client who has severe anxiety alone. The nurse's priority is to use the least restrictive intervention, such as staying with the client and calmly encouraging him to express his feelings.
A nurse administers a depression screening to a group of older adults at a senior center. Which of the following levels of prevention is this an example of? a. Primary prevention. b. Secondary prevention. c. Tertiary prevention. d. Quarternary prevention.
Correct: b. Secondary prevention Response Feedback: ATI Chapter 6, p. 32 Secondary prevention focuses on early detection and diagnosis of mental illness.
A nurse is caring for a client whose spouse died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? a. The client joined a bowling league 2 months ago. b. The client has kept his spouse's closet untouched since her death. c. The client exercises at a local health facility 3 days each week. d. The client meets his daughter for dinner every week.
Correct: b. The client has kept his spouse's closet untouched since her death Response Feedback: ATI Chapter 27, p. 162 The inability or refusal to clean out his spouse's closet in the 5 years since her death indicates the client is experiencing maladaptive grief.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? a. "I'm sure that the bugs you see will not harm you." b. "Tell me more about the bugs that you see in your room." c. "I don't see any bugs, but you seem very frightened." d. "I do not see anything. This is part of the withdrawal process."
Correct: c. "I don't see any bugs, but you seem frightened." Response Feedback: ATI Chapter 3, p. 17; Varcarolis, Chapter 8 p. 98-99 This response by the nurse presents reality and shows empathy by acknowledging the client's feelings.
A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? a. "I journal when I find it difficult to talk." b. "I pray when I begin to breathe fast." c. "I fix myself a pot of coffee when I get anxious." d. "I exercise when my neck is tense."
Correct: c. "I fix myself a pot of coffee when I get anxious." Response Feedback: ATI Chapter 9, p. 47-48 Clients who are experiencing stress or anxiety should eliminate or decrease the intake of caffeine.
A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic? a. "Everyone feels better after showering." b. "You must be getting better. You look great!" c. "I see you have done some grooming today." d. "Why are you all dressed up today? Is it a special occasion?"
Correct: c. "I see you have done some grooming today." Response Feedback: ATI Chapter 3, p 17; Varcarolis, Chapter 8 p. 98-99 "I see you have done some grooming today" is giving recognition, which indicates awareness of change and personal efforts and does not imply good or bad, right or wrong.
A nurse is explaining milieu therapy to a group of student nurses on the mental health unit. Which statement by the student nurse demonstrates a need for further teaching? a. "I should promote choices for clients within their daily routines." b. "I should help keep the nursing unit clean and orderly." c. "I should perform cares for clients so that they can spend their energy getting better. d. "I should model good behavior for clients."
Correct: c. "I should perform cares for clients so that they can spend their energy getting better." Response Feedback: ATI Chapter 5, p. 25 The goal of milieu therapy is to promote independence for self-care and individual growth in clients.
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make? a. "It will help you feel better if you talk about it." b. "I'll come back when you feel like talking." c. "I'll stay with you a few minutes." d. "Coming with me to the day room will take your mind off your troubles."
Correct: c. "I'll stay with you a few minutes." Response Feedback: ATI Chapter 3 p. 17; V arcarolis, Chapter 8 p. 98-99 "I'll stay with you a few minutes" is an example of offering self. This demonstrates a willingness to spend time with the client and indicates to the client that the nurse is genuinely concerned.
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? a. "My parents treat me like a baby sometimes." b. "I haven't gotten my period yet, and all my friends have theirs." c. "None of the kids at this school like me, and I don't like them either." d. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct: c. "None of the kids at school like me, and I don't like them either." Response Feedback: ATI Chapter 1, p. 4 Mentally healthy children and adolescents trust others, view the world as safe, accurately interpret their environments, master developmental skills, and use appropriate coping skills. None of the kids at school like me and I don't like them either is an inaccurate interpretation of environment and lack of trust which can indicate mental illness.
A nurse is caring for a client admitted to a mental health facility who asks, "Can I refuse the electroconvulsive therapy (ECT) treatment scheduled for tomorrow?" Which of the following should be the nurse's response? a. "You have already given signed consent for the treatments after they were explained to you." b. "You will feel better after the course of treatments." c. "You have the right to refuse even though the consent form has been signed." d. "You can refuse them, but the provider may be upset with you."
Correct: c. "You have the right to refuse even though the consent has been signed." Response Feedback: ATI Chapter 2, p. 9 A client has the right to refuse treatment even though the consent form has been signed.
A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make? a. "You should call your boss and ask if you can have your job back." b. "I don't understand why your partner would upset you with news like that." c. "You must feel very concerned and disappointed by that information." d. "There really isn't much you can do about that until you are discharged."
Correct: c. "You must feel very concerned and disappointed by that information." Response Feedback: ATI Chapter 3, p. 17; Varcarolis, Chapter 8 p. 98-99 This is a therapeutic response and an open-ended empathetic statement that encourages the client to talk.
Which of the following is an example of countertransference? a. A client is angry and hostile towards a nurse because the nurse reminds him of his abusive sister. b. A client becomes infatuated with the nurse and demands extra sessions. c. A nurse who had an eating disorder becomes frustrated with a client who has an eating disorder and continues to lose weight. d. A nurse accepts a gift from a client.
Correct: c. A nurse who had an eating disorder becomes frustrated with a client who has an eating disorder and continues to lose weight Response Feedback: ATI p. 26 A nurse who had an eating disorder becomes frustrated with a client who has an eating disorder and continues to lose weight is an example of countertransference, where the nurse overly identifies with the client.
A client receives a terminal illness diagnosis. The client tells the nurse, "I know I will die from this, but if I only live to see my daughter's wedding, it will be okay." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving? a. Denial b. Anger c. Bargaining d. Depression
Correct: c. Bargaining Response Feedback: ATI Chapter 27, p. 162 Bargaining is where the client negotiates for more time or a cure.
A nurse is admitting a client to the mental health unit following a recent suicide attempt. Which of the following actions should the nurse take? a. Place metal utensils on the client's meal tray. b. Assign the client to a private room furthest from the nurse's station. c. Inspect the client's personal belongings for items that could cause harm. d. Tuck bedcovers over client's hands and arms.
Correct: c. Inspect the client's personal belongings for items that could cause harm Response Feedback: ATI Chapter 5, p. 26 Inspecting the client and his personal belongings is an appropriate intervention to ensure that the client does not have access to potentially harmful objects.
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms? a. Reaction-formation b. Compensation c. Rationalization d. Suppression
Correct: c. Rationalization Response Feedback: ATI Chapter 4, p. 20-21 Rationalization is creating reasonable and acceptable explanations for behavior.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy? a. Encouraging client feedback about satisfaction with the facility experience. b. Explaining unit rules and policies regarding unacceptable behaviors. c. Supporting the client's wish to refuse prescribed medications. d. Making sure the client understands expectations for client participation.
Correct: c. Supporting the client's wish to refuse prescribed medications Response Feedback: MH ATI chapter 2, p. 9 Autonomy is the client's right to make their own decisions.
Which of the following clients would meet criteria for admission to an acute mental health care unit? a. The client with alcoholism who is stable after detoxification and ready to begin treatment. b. The client with moderate anxiety who needs cognitive behavioral therapy. c. The client who has told family members that he is planning to kill himself. d. The client who has dementia and needs assistance with activities of daily living.
Correct: c. The client who has told family members that he is planning to kill himself Response Feedback: ATI Chapter 6, p. 31 The client who is in danger of hurting himself or others needs intensive treatment and supervision in locked units.
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion? a. "Clients should be given medications even if they refuse them." b. "Nurses do not have to follow policies regarding the use of restraints for clients who are admitted involuntarily." c. "Clients who are admitted involuntarily can demand and obtain release from the facility." d. "Clients who are involuntarily admitted have the right to request a legal review of the admission at any time."
Correct: d. "Clients who are involuntarily admitted have the right to request a legal review of the admission at any time." Response Feedback: ATI Chapter 2, p. 10; Varcarolis, Chapter 6 p. 63 Clients who are involuntarily admitted have the right to request a legal review of the admission at any time.
A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? a. "Of course people care. Your family comes to visit every day." b. "Why do you feel that way?" c. "Tell me who you think doesn't care about you." d. "I care about you, and I am concerned that you feel so sad."
Correct: d. "I care about you, and I am concerned that you feel so sad." Response Feedback: ATI Chapter 3, p. 17; Varcarolis, Chapter 8 p. 98-99 "Of course people care. Your family comes to visit every day." Rationale: Trying to convince the client that his family members care about him is false reassurance that minimizes the feelings he just communicated. "Why do you feel that way?"Rationale: Asking the client a "why" question minimizes his feelings and is nontherapeutic. "Tell me who you think doesn't care about you."Rationale: By asking the client to tell what people don't care about him, the nurse is challenging the client's beliefs and changing the focus of the client away from his feelings and onto another subject.
A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse? a. "Evidence must exist prior to reporting." b. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." c. "I don't want to defame someone if the report is false." d. "If suspicion of abuse exists then reporting is mandatory."
Correct: d. "If suspicion of abuse exists then reporting is mandatory." Response Feedback: MH ATI Chapter 2, p. 10 It is mandatory to report suspicion of abuse.
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching? a. "The legal requirement for client confidentiality ceases if the client is deceased." b. "Staff members are required to divulge information to attorneys if they call for information." c. "Health care workers are not required to answer a court's requests for information about a client's disclosure." d. "Providers are required to warn individuals if the client threatens harm."
Correct: d. "Providers are required to warn individuals if the client threatens harm." Response Feedback: ATI Chapter 2, p. 9 Health care professionals have a duty to warn and protect third party individuals who may be in danger due to the client's threats of harm.
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make? a. "Perhaps you should discuss this with your physician." b. "Of course you aren't going to die, at least not in the immediate future." c. "I recommend you exercise daily and avoid smoking to decrease your risk." d. "Tell me more about these fears of dying from a heart attack."
Correct: d. "Tell me more about these fears of dying from a heart attack." Response Feedback: ATI Chapter 3 p. 17; Varcarolis, Chapter 8 p. 98-99 "Tell me more about these fears of dying from a heart attack" helps the client explore his fear of dying more fully.
A charge nurse in a mental health unit is discussing types of admissions with staff nurses. Which of the following situations would be a reason for a provider to change the admission status of a client from voluntary to involuntary? a. "When the client decides to sign out of the facility." b. "When the client refuses to go to therapy sessions." c. "When the client refuses medications." d. "When the client threatens to harm himself."
Correct: d. "When the client threatens to harm himself." Response Feedback: ATI Chapter 2, p. 10; Varcarolis, Chapter 6 p. 63 An involuntary admission is necessary when a client is in need of psychiatric treatment, presents a danger to self or others, or is unable to meet his or her own basic needs.
A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take? a. Identify other housing options and sources of transportation. b. Notify the facility chaplain to request scheduling an appointment. c. Confirm that everything will be all right because belongings can be replaced. d. Acknowledge the client's feelings of being overwhelmed.
Correct: d. Acknowledge the client's feelings of being overwhelmed Response Feedback: ATI Chapter 27, p. 162-163 This demonstrates therapeutic communication. During the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available.
A nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? a. Personal space. b. Eye contact. c. Posture. d. Intonation.
Correct: d. Intonation Response Feedback: ATI Chapter 3, p. 18 Intonation is the tone of one's voice and can communicate a variety of feelings.
A client tells the nurse, "You and that other nurse were talking about me, weren't you?" The nurse replies, "We were discussing ways to help you relate to the other clients in a more positive way." Which ethical principle is the nurse demonstrating? a. Autonomy b. Justice c. Fidelity d. Veracity
Correct: d. Veracity Response Feedback: MH ATI chapter 2, p. 9 Veracity is honesty when dealing with a client.
