ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Question 1 of 5
A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Monitor the child's vital signs every 15 minutes. This action is crucial to ensure the child's safety while in restraints. Monitoring vital signs every 15 minutes allows the nurse to promptly identify any signs of distress or complications related to the restraints, such as changes in blood pressure, heart rate, or respiratory rate. This frequent monitoring ensures early intervention if necessary, promoting the child's well-being.
Choice A (Keep the restraints on for a minimum of 1 hour) is incorrect because there is no specific time frame mentioned in best practice guidelines for keeping restraints on, and it is essential to assess the need for restraints continuously.
Choice C (Ask the provider to renew the prescription for the restraints every 24 hours) is incorrect as it focuses on administrative tasks rather than immediate patient safety monitoring.
Choice D (Arrange an in-person evaluation by the child's provider within 2 hours of initiating restraints) is incorrect as it does not address
Question 2 of 5
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Statement A reflects countertransference as it indicates a personal connection between the nurse and the client based on the nurse's past experience with their brother. This can lead to biased care.
Summary:
- Statement B is focused on the client's responsibility.
- Statement C is about the client's behavior during therapy.
- Statement D is about the client's request for a date with the nurse, which is boundary crossing.
Question 3 of 5
A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Initiate fall precautions for the client. Lorazepam is a benzodiazepine that can cause sedation and drowsiness, increasing the risk of falls. Fall precautions should be implemented to ensure the client's safety.
Choice A is incorrect because repeating the dose can lead to overdose.
Choice C is incorrect as lorazepam does not typically cause ringing in the ears.
Choice D is inappropriate and unethical unless absolutely necessary for the client's safety, which is not indicated in this scenario.
Question 4 of 5
A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?
Correct Answer: D
Rationale: The correct answer is D: Establish confidentiality guidelines with the client. This is the first step to building trust in the nurse-client relationship, essential in mental health care. Confidentiality assures the client that their personal information will be kept private, promoting openness and honesty. By discussing confidentiality guidelines upfront, the nurse shows respect for the client's privacy and fosters a safe environment for them to share sensitive information.
Choices A, B, and C focus on interventions that come later in the nurse-client relationship. Helping the client use coping strategies, make behavioral changes, and educating them about their disorder are important steps but should follow after establishing trust and confidentiality. It is crucial to prioritize building a strong foundation of trust before moving on to other aspects of care.
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 5 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.