ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Vital Signs
Admission, 1600:
Temperature: 36.1° C (97° F)
Blood pressure: 98/66 mm Hg
Heart rate: 76/min
Respiratory rate: 10/min
Pulse oximetry: 95% on room air
Diagnostic Results
Blood alcohol level (BAC): 310 mg/dL (0 to 50 mg/dL)
History & Physical
Neurological: Client is intoxicated, has slurred speech, and is unable to coherently respond to questions.
Cardiovascular: Normal sinus rhythm and pulses palpable. No history of heart disease.
Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders and client states they quit smoking over 20 years ago.
Gastrointestinal: Client reports weight loss over the past 3 months and minimal appetite.
Genitourinary: Client reports no known problems.
Impression: Relapse of alcohol use disorder.
Plan: Admit for alcohol use disorder and observe for alcohol withdrawal.
Nurses’ Notes
Client brought in by a family member who states that the client has been drinking “nonstop since the death of the client’s parents 3 months ago.”
Client has a history of alcohol use disorder for over 20 years.
Client attended an inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.
According to the client’s family member, the client has been unable to cope with the sudden death of their parents.
Client is currently unemployed after being laid off.
Client’s family member states, “Everything combined caused the drinking to start again.”
Family member estimates the client’s last drink was 2 hours ago.
Question 1 of 5
A nurse in a mental health facility is admitting a client.Exhibits:A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.
Correct Answer: A,C,D,F,G
Rationale: The correct answers are A, C, D, F, and G. A gastrointestinal assessment is needed to monitor for any alcohol-related issues like GI bleeding. Blood alcohol level monitoring is crucial to assess intoxication levels. Recent loss can trigger alcohol use, requiring emotional support. Recent alcohol consumption indicates ongoing abuse. Neurological assessment is needed for potential alcohol-related brain damage. Smoking history and genitourinary assessment are not directly related to alcohol use disorder and do not require immediate follow-up in this scenario.
Question 2 of 5
A nurse in a mental health facility is admitting a client.Exhibits:A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.
Correct Answer: A,C,D,F,G
Rationale: The correct answers are A, C, D, F, and G. A gastrointestinal assessment is needed to monitor for any alcohol-related issues like GI bleeding. Blood alcohol level monitoring is crucial to assess intoxication levels. Recent loss can trigger alcohol use, requiring emotional support. Recent alcohol consumption indicates ongoing abuse. Neurological assessment is needed for potential alcohol-related brain damage. Smoking history and genitourinary assessment are not directly related to alcohol use disorder and do not require immediate follow-up in this scenario.
Extract:
Question 3 of 5
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?
Correct Answer: D
Rationale: The correct answer is D. When the client is able to follow commands, it indicates that they have regained control and are not a danger to themselves or others. This criterion ensures the safe removal of physical restraints.
Choice A is incorrect as orientation alone does not guarantee the client's safety.
Choice B is incorrect because medication refusal does not necessarily indicate safety.
Choice C is incorrect as the client's verbal threat of harm is not a reliable indicator of their actual intentions.
Question 4 of 5
A nurse is assessing a client during a follow-up at a health clinic. The client reports that they struggle to take antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?
Correct Answer: C
Rationale: The correct answer is C: Ask the client if the medication is causing adverse effects. This is the most appropriate action to improve medication adherence because it addresses a potential barrier to taking the medication regularly. By inquiring about adverse effects, the nurse can assess if the client is experiencing any side effects that may be impacting their ability or willingness to take the medication. By identifying and addressing these issues, the nurse can work with the client to find solutions or alternatives to improve adherence.
Other choices are incorrect:
A: Threatening admission to an inpatient care facility is coercive and not a respectful or effective approach to improving adherence.
B: Discussing provider goals may not directly address the client's challenges with medication adherence.
D: Requesting a second medication without addressing the underlying issues may not solve the problem and can lead to further complications.
Question 5 of 5
A nurse in an acute care facility is planning care for a client with a history of alcohol use disorder who is admitted while intoxicated. Which of the following interventions should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. Alcohol withdrawal can lead to seizures, so seizure precautions are crucial for safety. Monitoring for orthostatic hypotension (
B) is important but not the priority. Administering methadone hydrochloride (
C) is not indicated for alcohol withdrawal. Acidifying the client's urine (
D) is not relevant to the situation.