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ATI MENTAL HEALTH Exam -1, Verified Correct Answers-40 -QA

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ATI MENTAL HEALTH Exam -1, Verified Correct Answers-40 -QA ATI Mental Health Exam 1. As a nurse approaches a client with schizophrenia, the client looks at the nurse and says, “Back off. Leave me alone.” The client appears tense and is pacing rapidly. Which of the following is an appr...

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  • February 17, 2021
  • 17
  • 2020/2021
  • Exam (elaborations)
  • Questions & answers

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  • ati mental health exam 1
  • verified correct answers 40 qa

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ATI Mental Health Exam




1. As a nurse approaches a client with schizophrenia, the client looks at the
nurse and says, “Back off. Leave me alone.” The client appears tense and is
pacing rapidly. Which of the following is an appropriate nursing response?
a. “I can’t leave you alone when you are this upset. Sit down, and try to
relax.”
b. “Let’s go to your room, and you can tell me what is bothering you.”
c. “I will give you space as long as you control yourself. I’d like to know
what is causing you to feel so tense.”
d. “I will leave you alone for a few minutes while you try to compose
yourself.”

The nurse’s first concern is to ensure safety. To avoid escalating the client’s
behavior, the nurse should stay at the comfortable distance and remain calm while
stressing the importance of maintaining control. Verbal intervention is the least
restrictive form of action. If the client does not respond to verbal interventions,
then more restrictive measures may have to be used.




2. A nurse on a mental health care unit is providing care for a client diagnosed
with schizophrenia. The client is experiencing delusional thinking. Which of
the following defense mechanisms is the client using when making
delusional statements?

, a. Projection
b. Dissociation – a client detaches emotional or behavioral processes from
usual conscious behavior patterns or identity. There is not indication that
the client has amnesia problems
c. Displacement – a client redirects an emotion from the original object to a
more acceptable substitute. Displacement is not the defense mechanism
used in delusional thinking
d. Regression – a client attempts to reduce anxiety and conflict by returning
to less mature behaviors that help the client better tolerate the anxiety.
Regression is not the defense mechanism used in delusional thinking.

In projection a client attributes unacceptable emotions and qualities to others. This
is the defense mechanism that is operative in delusive thinking




3. A client diagnosed with schizophrenia says to the nurse, “They lied about
me and are trying to poison my food.” Which of the following is a
therapeutic nursing response?
a. “Tell me who would do such things to you?”
b. “You are mistaken. Nobody has told lies about you or tried to poison
you.”
c. “Tell me more about your concerns about being poisoned.”
d. “You’re having very frightening thoughts.”

, Fear of being poisoned is a common delusion among the client with schizophrenia.
The nurse is responding therapeutically to the feelings that the client is attempting
to communicate. By doing this, the nurse is shifting the focus from the beliefs,
which are not real, to the client’s fear, which is real.




4. A client is hospitalized with schizophrenia. During a conversation with the
nurse, the client seems relaxed initially, but then com restless and begin
wringing his hands. The nurse states that the client seems tens, and the client
agrees. Which statement by the nurse would be appropriate at this time?
a. “Did I say something wrong that made you feel tense?”
b. “Do you often feel tense when you are talking to a health care provider?”
c. “What were we discussing when you began to feel uncomfortable?”
d. “I sometimes feel tense, too, when I am talking to stranger.”

This statement seeks clarification by asking for information about when the client
became tense. This open-minded question is therapeutic because it encourages
further communication and expression of feeling.

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