ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Question 1 of 5
A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "Can you tell me how you have been feeling lately?" This response shows empathy and encourages the client to express their emotions, which is crucial in assessing their mental state. By asking about the client's feelings, the nurse can gather important information to evaluate the severity of the depression and assess any suicidal ideation.
Choice B is not the best response as it may come off as judgmental or accusatory.
Choice C minimizes the client's feelings and does not address the seriousness of the situation.
Choice D may be helpful but is not the immediate priority in this scenario.
Question 2 of 5
A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Intense efforts to avoid abandonment. Individuals with borderline personality disorder often exhibit fear of abandonment leading to intense efforts to avoid it. This behavior is a key feature of the disorder, characterized by frantic attempts to avoid real or imagined separation. This finding is supported by the Diagnostic and Statistical Manual of Mental Disorders criteria for borderline personality disorder.
Choices A, B, and C are incorrect because while individuals with borderline personality disorder may experience difficulty in maintaining employment, have impulsivity leading to reckless spending or hoarding, and struggle with unstable relationships, the most characteristic feature related to the fear of abandonment is intense efforts to avoid it.
Question 3 of 5
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Obtain a prescription for seclusion within 30 minutes. This action is crucial as seclusion should only be implemented with a physician's order to ensure the client's safety and rights are protected. The nurse must promptly obtain this order to ensure the client's needs are met in a timely manner.
Choice A is incorrect because documenting the client's behavior every 60 minutes does not address the immediate need for a physician's order for seclusion.
Choice B is incorrect as there is no specific time limit for seclusion, and it should only be ended with a physician's approval.
Choice D is incorrect as monitoring vital signs every 4 hours is important but not as urgent as obtaining the seclusion prescription.
Extract:
Vital Signs
0200:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 104/min
o Respiratory rate: 18/min
o Blood pressure: 158/96 mm Hg
o Oxygen saturation: 98% on room air
0415:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 108/min
o Respiratory rate: 20/min
o Blood pressure: 148/94 mm Hg
o Oxygen saturation: 98% on room air
Nurses’ Notes
0205:
The client was brought to the ED by police after being found wandering on the street. The client was able to provide their identity to the police, but was not able to identify the place or time. The family was notified. The client appeared confused and agitated. Their appearance was disheveled. Their mucous membranes were dry. Their lungs were clear and equal, and their heart rhythm was regular. During the assessment, the client stated, “Can you ask that person to leave my room?” The client was pointing to an empty chair.
0230:
The client’s adult child arrived at the ED and went to the client’s room. The client identified the family member. The client was pacing and agitated, and stated, “I don’t understand why I am here.” The adult child asked the nurse to talk outside of the room and stated, “I don’t know why they are so confused. They are not normally like this.” The adult child stated that the client has a past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, the client voided 250 mL of dark yellow, cloudy urine.
0415:
The client was admitted to the medical-surgical unit. A peripheral IV was initiated in the right arm. The client was agitated, trying to pull out the IV, and yelling, “I am leaving now!”
Provider’s Note
0230: Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
0400: The client will be transferred to the medical-surgical unit.
Laboratory Results
0230: Serum toxicology screen: Alcohol 60 mg/dL (80 to 200 mg/dL indicates mild to moderate intoxication)
Question 4 of 5
The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.Exhibits:Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.
Correct Answer: B,D,E
Rationale: The correct answer is B, D, and E. Reorienting the client helps maintain their cognitive function. Approaching slowly minimizes agitation and builds trust. Maintaining a low-stimulation environment supports the client's well-being. A is incorrect as family support can be beneficial. C is unnecessary unless there are specific reasons.
Extract:
Question 5 of 5
A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?
Correct Answer: C
Rationale: The correct answer is C: Blood glucose 256 mg/dL (74 to 106 mg/dL). Elevated blood glucose levels can be a side effect of risperidone, an atypical antipsychotic medication. Notify the provider to assess for potential hyperglycemia, which can lead to serious complications like diabetic ketoacidosis.
A, B, and D are within normal ranges. A slightly low or high sodium level, WBC count, or platelet count are not typically concerning in this case.