ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 of 5
A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?
Correct Answer: C
Rationale: The correct answer is C: WBC Count 13,000/mm. Elevated white blood cell count can indicate an underlying infection, which is a common cause of delirium in older adults. Infections can lead to systemic inflammation that affects the brain, resulting in delirium. Hypertension (
A) and neuropathy (
B) do not directly increase the risk of delirium. BUN level of 16 mg/dL (
D) is within normal range and not specifically linked to delirium.
Question 2 of 5
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Correct Answer: B
Rationale: The correct answer is B: Notify the client about designated times for meals. This intervention is important for clients with anorexia nervosa to establish a structured eating routine, prevent skipping meals, and promote regular eating habits. By notifying the client about designated times for meals, the nurse helps the client maintain a consistent and balanced diet, which is crucial for the treatment of anorexia nervosa. Weighing the client weekly (
A) may lead to increased anxiety and obsession with weight. Negotiating weight gain (
C) could reinforce unhealthy behaviors. Decreasing fiber intake (
D) is not a recommended intervention as it may compromise the client's nutritional intake.
Question 3 of 5
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
Correct Answer: C
Rationale: The nurse should see client C first because clozapine, an antipsychotic medication, can cause agranulocytosis which presents with sore throat as an early sign. This is a potentially life-threatening condition that requires immediate attention to prevent complications. Clients A and B are displaying symptoms related to their mental health conditions but are not indicating urgent medical issues. Client D reporting weight gain is a common side effect of lithium and does not require immediate intervention compared to potential agranulocytosis in client C.
Question 4 of 5
A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Establish a rapport to foster trust. This should be the first action as building a therapeutic relationship with the client is crucial for effective care. Trust is essential for the client to open up and engage in treatment. Continuous one-to-one observation (
A) may be necessary but establishing trust comes first. Asking the client to sign a no-suicide contract (
B) is important but should come after establishing rapport. Encouraging participation in group therapy (
C) may be beneficial but not the initial priority.
Question 5 of 5
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Failure to recognize familiar objects. In Alzheimer's disease, individuals often experience cognitive decline, including memory loss and difficulty recognizing familiar objects or people. This is due to the progressive deterioration of brain cells, particularly in areas responsible for memory and perception. Excessive motor activity (
A) is not a typical finding in Alzheimer's and may be more indicative of other conditions. Altered level of consciousness (
C) typically refers to a decrease in alertness, which is not a primary symptom of Alzheimer's. Rapid mood swings (
D) may occur in some individuals with Alzheimer's but are not as consistently observed as the failure to recognize familiar objects.