ATI RN
Mental Health ATI RN Questions
Question 1 of 5
A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: Crackles are abnormal lung sounds that may indicate the presence of fluid or mucus in the lungs. Placing the client on bed rest in a semi-Fowler position helps to improve lung expansion and oxygenation by reducing the pressure on the diaphragm promoting optimal lung ventilation and facilitating drainage of fluid from the affected area of the lung. Fluid restriction is typically for conditions like heart failure not crackles. Antibiotics require evidence of infection and repeating auscultation does not immediately improve oxygenation.
Question 2 of 5
The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior?
Correct Answer: D
Rationale: This response demonstrates the use of therapeutic communication specifically offering the client an opportunity to express their feelings and concerns in a non-confrontational manner. By suggesting a private and quiet area to talk to the nurse provides a safe and supportive environment for the client to explore and process their emotions. This approach can help the client feel heard validated and understood which may reduce their need to act out or engage in argumentative behaviors to express their feelings. Threats medication demands or dismissive comments may escalate behavior.
Question 3 of 5
A nurse is caring for a child who is on a clear liquid diet. At lunch the child consumed 1/2 cup of juice 3 oz gelatin 1 oz of an ice pop and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?
Correct Answer: 260 mL
Rationale:
Step 1: Convert 1/2 cup of juice to mL: 1 cup = 240 mL so 1/2 cup = 120 mL.
Step 2: Convert 3 oz of gelatin to mL: 1 oz = 30 mL so 3 oz = 90 mL.
Step 3: Convert 1 oz of ice pop to mL: 1 oz = 30 mL.
Step 4: Ginger ale is 20 mL.
Step 5: Sum: 120 mL + 90 mL + 30 mL + 20 mL = 260 mL. The nurse should record 260 mL.
Question 4 of 5
A client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?
Correct Answer: A
Rationale: Malpractice refers to a legal claim that can be made against healthcare professionals including nurses and hospitals when they fail to provide the standard of care expected in their profession resulting in harm or injury to a patient. In this case the lack of documentation that the client was assessed every hour as prescribed can be seen as a failure to meet the standard of care for a client with depression at risk for self-harm. This failure may have contributed to the client's suicide attempt constituting malpractice. Battery false imprisonment and assault do not apply as there was no intentional contact restraint or threat.
Question 5 of 5
After an angry outburst a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?
Correct Answer: B
Rationale: When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking What happened that got you so upset? the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective provide appropriate support and potentially de-escalate any remaining tension. Dismissing focusing on the nurse’s feelings or judging the behavior hinders therapeutic communication.