ATI RN
ATI nsg 133 Mental Health Exam Questions
Extract:
Medical History
Diagnosed with ADHD 4 years ago when the adolescent was 10 years old. Started on methylphenidate 10 mg PO BID therapy 6 months ago January).
Vital Signs
January:
Baseline weight and vital signs:
• Temperature 36.4° C (97.5" F)
• Heart rate 92/min
• Respiratory rate 20/min
• Blood pressure 112/74 mm Hg
• Oxygen saturation 98% on room air
• Weight 39.9 kg (88 lb)
• BMI 19
June:
Weight and vital signs:
• Temperature 37° C (98.6° F)
• Heart rate 84/min
• Respiratory rate 20/min
• Blood pressure 110/70 mm Hg
• Oxygen saturation 98% on room air
• Weight 39.9 kg (88 lb)
• BMI 18.8
Nurses' Notes
Adolescent is brought to the clinic by guardians following a motor-vehicle crash earlier this week. Guardians report the adolescent "borrowed" their car and ran it into a tree. The adolescent hit their head on the steering wheel and cut their forehead. There are six sutures dry and intact on the adolescent's forehead. Adolescent is oriented to person, place, and time. Follows simple commands, moves all extremities without difficulty, denies pain. Pupils are equally round, reactive to light and accommodation. Guardians report adolescent has recently been caught sneaking out of the house during the middle of the night and roaming the neighborhood alone, and the adolescent has been getting in trouble at school for not following teachers' directions and walking out of the classroom. Guardians state, "We are at a loss of what to do."
Question 1 of 5
A nurse in a clinic is caring for an adolescent. Complete the following sentence by using the lists of options. The adolescent is at greatest risk for ---------------------- as evidenced by the adolescent's-------------------------------
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Injury; Parameter to Monitor: Impaired social interaction, Discourteous behavior.
Rationale:
1. Action A (Impaired social interaction) and B (Discourteous behavior) are correct as they are common issues in adolescents that can lead to risky behaviors.
2. Potential Condition "Injury" is the consequence of impaired social interaction and discourteous behavior, making it a valid concern.
3. Monitoring Impaired social interaction and Discourteous behavior helps assess the adolescent's risk for potential injuries due to their behavior.
4.
Choices C, D, and E are incorrect as they do not directly relate to the adolescent's behaviors and social interactions, which are crucial in assessing injury risk.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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