what assessment question should the nurse ask when attempting to determine a teenagers mental health resilience select one that doesnt apply
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2023

1. When attempting to determine a teenager's mental health resilience, what assessment question should the nurse ask that is not applicable?

Correct answer: D

Rationale: Assessing a teenager's mental health resilience involves exploring coping mechanisms, support systems, and attitudes towards seeking help. Option D is not relevant to assessing resilience but rather focuses on the comparison between seeking advice from a counselor versus the nurse, which doesn't directly gauge the teenager's resilience.

2. A patient with generalized anxiety disorder (GAD) is prescribed buspirone. The nurse understands that buspirone is different from benzodiazepines because it:

Correct answer: C

Rationale: Buspirone is different from benzodiazepines because it does not cause sedation. Unlike benzodiazepines, buspirone has a lower potential for abuse and does not cause the sedative effects commonly seen with benzodiazepines. While benzodiazepines may work immediately to relieve anxiety, buspirone may take longer to show its therapeutic effects. Additionally, buspirone is not limited to short-term treatment only, making it a preferred choice in patients where sedation is a concern or in those with a history of substance abuse.

3. A client has been diagnosed with major depressive disorder. Which is an appropriate short-term goal for the client?

Correct answer: A

Rationale: Setting a goal for the client to report a decrease in depressive symptoms is appropriate as it is specific, measurable, and achievable in the short term. Monitoring changes in depressive symptoms provides valuable feedback on the effectiveness of the treatment plan. While establishing a sleep routine, improving social interactions, and setting realistic goals for the future are important aspects of recovery, they are more suitable as intermediate or long-term goals. In the context of short-term goals, focusing on symptom reduction can provide immediate feedback on the client's progress and help adjust the treatment plan accordingly.

4. A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, 'I work hard to provide for my family. I don't see why I can't drink to relax.' The nurse recognizes the use of which defense mechanism?

Correct answer: B

Rationale: The nurse should recognize that the client is using rationalization, a common defense mechanism. Rationalization involves creating logical reasons to justify unacceptable feelings or behaviors. In this scenario, the client is justifying excessive drinking by linking it to hard work and the need for relaxation, masking the true underlying issue of alcohol abuse. Projection involves attributing one's thoughts or feelings to others, regression involves reverting to an earlier stage of development, and sublimation involves channeling unacceptable impulses into socially acceptable activities, none of which are demonstrated in the client's statement.

5. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.

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