ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Medical History
A 21-year-old client was brought to the emergency department by their college friend. The friend reports that the client has been in their room for a week and has not bathed or attended class for one week. Current medications include venlafaxine 150 mg daily. The client denies the use of over-the-counter and herbal medications but has thought about starting St. John’s Wort to help with symptoms.
Nurses’ Notes
0800: The client is dressed in wrinkled sweatpants, a stained t-shirt, and is sitting alone at breakfast. The client ate one bite of toast. The client makes no eye contact, stands up slowly, and asks to go back to the room to sleep.
0945: The client is out in the day room after sleeping for 1 hour. The client is walking with their head down. The client reports having no interest in classes or contacting friends and states, “I just feel so sad and hopeless right now.” The client lost their parents in a car accident at age 18 and fell into a deep depression. The client tried therapy and an antidepressant and found the interventions effective.
Question 1 of 5
A behavioral health unit nurse is caring for a newly admitted client.Exhibits:Complete the following sentence by using the lists of options: The client demonstrates risk for ___ due to ___.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: -; Parameter to Monitor: D, E.
Rationale:
- Feelings of hopelessness and powerlessness are common in clients at risk for self-harm, as they may feel overwhelmed and lack control. Monitoring self-harm behaviors and sleep disturbances (insomnia) can help assess the client's safety and mental well-being. Inadequate nutrition is not directly related to the client's risk for self-harm. The inclusion of "hopelessness" as a parameter to monitor is redundant since it is already mentioned in the correct actions to take.
Extract:
Question 2 of 5
For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?
Correct Answer: D
Rationale: The correct answer is D because a nurse is mandated to report any suspicion of child abuse or neglect, such as the partner tying the child to a bed. This falls under the category of child maltreatment, which must be reported to the appropriate agency to ensure the safety and well-being of the child.
Choices A, B, and C do not involve immediate harm to a vulnerable individual and do not fall under the mandated reporting requirements for nurses.
Question 3 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale: The correct instructions are B, C, and E. Installing sensor devices on outside doors helps prevent wandering. Positioning the mattress on the floor reduces fall risk. Putting locks at the top of doors prevents the client from wandering. Placing the client in a reclining chair does not address the wandering issue. Encouraging physical activity prior to bedtime may increase agitation and worsen wandering.
Question 4 of 5
A nurse is caring for a client who has been taking quetiapine for 1 week and reports dizziness. The client asks the nurse if the dizziness indicates an allergic reaction to the medication. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "Dizziness is a common adverse effect of the medication and is related to low blood pressure." Quetiapine, an antipsychotic medication, commonly causes dizziness as a side effect due to its potential to lower blood pressure. This response educates the client about a known side effect of the medication and provides a logical explanation for the dizziness.
Rationale for Incorrect
Choices:
A: Incorrect. Taking the medication with a meal may help reduce gastrointestinal side effects but is not directly related to dizziness.
B: Incorrect. Dizziness does not necessarily indicate an allergic response, and stopping the medication abruptly without consulting a healthcare provider can be dangerous.
C: Incorrect. The timing of medication administration does not directly affect the occurrence of dizziness associated with quetiapine.
By providing education on the common adverse effect of quetiapine and its relation to dizziness, the nurse empowers the client with knowledge and promotes safe medication management.
Question 5 of 5
A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?
Correct Answer: C
Rationale: The correct answer is C: Improvement in manifestations of depression. Electroconvulsive therapy is primarily used to treat severe depression.
Therefore, improvement in depressive symptoms indicates the treatment's effectiveness. Reduced frequency of seizures (
A) is not relevant to ECT. Reduced panic attacks (
B) and decreased fear of heights (
D) are not direct indications of ECT effectiveness. Make sure to monitor for potential side effects of ECT such as memory problems.