Question

A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Ask the client about the lethality of their plan.

Rationale :

🔴 When a client expresses suicidal ideation, the first priority is safety, which includes assessing the lethality and specificity of the suicide plan.

🔴 Asking directly about the method, intent, and access helps determine the level of risk and urgency of intervention.

🔴 This approach is part of a standard suicide risk assessment and does not increase suicidal behavior.

🔴 Early identification allows the nurse to implement appropriate precautions (e.g., one-to-one monitoring, removal of dangerous items).

🔴 Documentation and immediate reporting to the care team are essential steps.

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Answer 2

Correct Answers:

"The stress from my new job could be the cause of my depressed mood"

Rationale :

🟣 Psychosocial stressors, such as work pressure, relationship strain, or loss, are known triggers for depression.

🟣 External events can activate underlying vulnerabilities in mood regulation, especially in individuals with predisposing factors.

🟣 This statement demonstrates an understanding of the environmental and situational origins of depressive symptoms.

🟣 Nurses should validate this insight and offer education on coping mechanisms and support systems.

🟣 Addressing these stressors is a central component of depression treatment planning.

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Answer 3

Correct Answers:

Tardive dyskinesia.

Rationale :

🟠 The Abnormal Involuntary Movement Scale (AIMS) is a tool used to assess for tardive dyskinesia (TD), a long-term adverse effect of antipsychotic medications.

🟠 TD includes involuntary, repetitive movements, especially in the face, mouth, and limbs.

🟠 The AIMS assessment helps track severity and progression and guide medication management.

🟠 Routine monitoring is critical in clients taking first-generation antipsychotics (e.g., haloperidol).

🟠 It is not used for substance withdrawal or lithium side effects.

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Answer 4

Correct Answers:

Depersonalization.

Rationale :

🔵 In panic-level anxiety, clients may experience dissociative symptoms such as depersonalization—a feeling of detachment from one’s body or self.

🔵 This represents a severe reaction to overwhelming fear and physiological arousal.

🔵 It impairs reality testing and is considered a hallmark of panic-level or severe anxiety.

🔵 The nurse should offer calm presence and grounding techniques.

🔵 Immediate safety and psychological support are essential in de-escalation.

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Answer 5

Correct Answers:

Ask the client about the lethality of their plan.

Rationale :

📝 Repeating this question confirms the principle that when suicidal ideation is expressed, the nurse must assess risk and intent immediately.

📝 Knowing how, when, and with what means the client plans to die helps determine intervention level (e.g., hospitalization, 1:1 observation).

📝 This action demonstrates both clinical competence and empathy, not judgment or dismissal.

📝 It is a therapeutic and safety-centered response to suicidal disclosure.

📝 The goal is risk reduction and care planning.

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Answer 6

Correct Answers:

Necklace.

Rationale :

🔴 A necklace poses a ligature risk, especially for clients admitted following a suicide attempt.

🔴 The priority is removing all potentially harmful personal items that can be used for self-strangulation or hanging.

🔴 Items like belts, shoelaces, and jewelry must be evaluated for safety upon admission.

🔴 The nurse should educate the family on the reason for this precaution and ensure the client feels safe and respected.

🔴 This action supports environmental safety and suicide prevention.

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Answer 7

Correct Answers:

Families where caregivers have college degrees or higher.

Rationale :

🎯 Parental education is a documented protective factor against adverse childhood experiences (ACEs).

🎯 Higher education is often associated with better parenting skills, emotional availability, and access to resources.

🎯 These families are more likely to provide stable, supportive environments that foster resilience and healthy coping.

🎯 Protective factors buffer children from the toxic stress caused by trauma.

🎯 Strengthening these supports is essential in early intervention and trauma prevention.

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Answer 8

Correct Answers:

"Experiencing or witnessing a traumatic event can result in developing a trauma-related disorder.".

Rationale :

💥 Trauma-related disorders, such as PTSD, often develop after a person has experienced or witnessed a traumatic event (e.g., violence, abuse, disasters).

💥 Trauma overwhelms the individual’s ability to cope or process the event, leading to lasting psychological effects.

💥 Not everyone who experiences trauma develops a disorder, but exposure is a necessary precursor.

💥 Understanding this helps normalize the experience and reduce stigma, encouraging people to seek help.

💥 The nurse’s role includes education, screening, and early referral.

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Answer 9

Correct Answers:

Adaptive vs. maladaptive.

Rationale :

🟢Understanding stress responses involves recognizing whether coping mechanisms are adaptive (healthy) or maladaptive (harmful).

🟢 This distinction helps nurses assess client behavior and guide them toward healthier responses.

🟢 Adaptive coping might include problem-solving or support-seeking, while maladaptive includes substance use or avoidance.

🟢 This framework helps nurses provide individualized and judgment-free care.

🟢 Avoiding moral labels like "good vs. bad" allows for therapeutic neutrality.

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Answer 10

Correct Answers:

Exhaustion Phase.

Rationale :

🟢 The Exhaustion phase is the third stage in Selye’s General Adaptation Syndrome (GAS).

🟢 It occurs when the body’s adaptive mechanisms are depleted due to prolonged or chronic stress.

🟢 In this phase, the immune system becomes compromised, increasing vulnerability to infections, such as recurring influenza.

🟢 Adolescents may show physical symptoms like illness or fatigue when stress is not managed.

🟢 This phase explains why the adolescent is experiencing recurrent manifestations of the same viral infection.

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RN ATI Custom Nur316-Fall 2023(Module 4 Units 1-5)

No.

1 :
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

2 :
A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?

3 :
A charge nurse in a mental health facility is teaching a newly licensed nurse how to perform an Abnormal Involuntary Movement Scale (AIMS) assessment on a client. The charge nurse should identify that the AIMS assessment is used for which of the following conditions?

4 :
A nurse on an inpatient mental health unit is caring for a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?

5 :
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

6 :
A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client’s partner to take back home?

7 :
A nurse is caring for a client who is concerned about developing a mental health disorder as a result of their childhood experiences. Which of the following familial characteristics is a protective factor for adverse childhood experiences?

8 :
A nurse is covering a phone triage line for trauma and crisis support. A client on the phone asks, "Can you help me understand how trauma-related disorders develop?' Which of the following responses by should the nurse provide?.

9 :
A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client?.

10 :
A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye's General Adaptation Syndrome (GAS) explains the possible cause for the adolescents manifestations?

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RN ATI Custom Nur316-Fall 2023(Module 4 Units 1-5)

No.

1 : A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

2 : A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?

3 : A charge nurse in a mental health facility is teaching a newly licensed nurse how to perform an Abnormal Involuntary Movement Scale (AIMS) assessment on a client. The charge nurse should identify that the AIMS assessment is used for which of the following conditions?

4 : A nurse on an inpatient mental health unit is caring for a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?

5 : A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

6 : A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client’s partner to take back home?

7 : A nurse is caring for a client who is concerned about developing a mental health disorder as a result of their childhood experiences. Which of the following familial characteristics is a protective factor for adverse childhood experiences?

8 : A nurse is covering a phone triage line for trauma and crisis support. A client on the phone asks, "Can you help me understand how trauma-related disorders develop?' Which of the following responses by should the nurse provide?.

9 : A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client?.

10 : A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye's General Adaptation Syndrome (GAS) explains the possible cause for the adolescents manifestations?

1 :
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

2 :
A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?

3 :
A charge nurse in a mental health facility is teaching a newly licensed nurse how to perform an Abnormal Involuntary Movement Scale (AIMS) assessment on a client. The charge nurse should identify that the AIMS assessment is used for which of the following conditions?

4 :
A nurse on an inpatient mental health unit is caring for a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?

5 :
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

6 :
A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client’s partner to take back home?

7 :
A nurse is caring for a client who is concerned about developing a mental health disorder as a result of their childhood experiences. Which of the following familial characteristics is a protective factor for adverse childhood experiences?

8 :
A nurse is covering a phone triage line for trauma and crisis support. A client on the phone asks, "Can you help me understand how trauma-related disorders develop?' Which of the following responses by should the nurse provide?.

9 :
A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client?.

10 :
A nurse is caring for an adolescent who is experiencing recurring manifestations of influenza. Which of the following phases of Selye's General Adaptation Syndrome (GAS) explains the possible cause for the adolescents manifestations?