ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Question 1 of 5
A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Symptoms suggest lithium toxicity, requiring blood tests. Improvement over time is false, continuing risks worsening, sodium reduction increases toxicity.
Question 2 of 5
A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?
Correct Answer: C
Rationale: Environmental cues (clocks, calendars) reduce confusion in delirium. Decision-making is impaired, family visits help, restraints increase agitation.
Question 3 of 5
A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: Low stimuli reduce hallucination intensity and agitation. Eye contact builds trust, socialization may overwhelm, and touch could be misinterpreted.
Extract:
Provider’s Note
0230:
Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
Vital Signs
0200:
Temperature 38.6° C (101.5° F)
Heart rate 104/min
Respiratory rate 18/min
Blood pressure 158/96 mm Hg
Oxygen saturation 98% on room air
Nurses’ Notes
0205:
Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police, but not able to identify place or time. Family notified.
Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular.
During assessment, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair.
0230:
Client’s adult child arrived to the ED and went to client’s room. Client identified family member. Client is pacing and agitated, and states, “I don’t understand why I am here.” Adult child asks nurse to talk outside of room and states, “I don’t know why they are so confused. They are not normally like this.” Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, client voided 250 mL of dark yellow, cloudy urine.
Laboratory Results
0230:
Serum toxicology screen:
Alcohol 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Question 4 of 5
The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.Exhibits:For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
| Options | Delirium | Alzheimer’s Disease |
|---|---|---|
| Sudden onset of confusion | ||
| Hallucinations | ||
| Agitation | ||
| Current medical diagnosis |
Correct Answer:
Rationale: Sudden confusion (
A) and medical diagnosis (
D) fit delirium; hallucinations (
B) and agitation (
C) occur in both.
Extract:
Question 5 of 5
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states, 'I can’t stand to be touched by another person.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Advocating for an alternative respects boundaries. Reassurance dismisses, gloves don’t help, probing is intrusive.