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: GI issues (
A), high BAC (
C), recent loss (
D), recent drinking (F), and neurological symptoms (G) need follow-up due to physical and psychological risks in alcohol use disorder. Others are stable or less urgent.
Extract:
Question 2 of 5
A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?
Correct Answer: A
Rationale: This statement indicates spiritual distress because it reflects a disruption in the client’s spiritual practice due to therapy scheduling. Meditation, a key spiritual routine, being interrupted can lead to disconnection and distress. Increased advisor visits, comfort from meditation, and faith giving hope suggest spiritual strength, not distress.
Question 3 of 5
A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, 'I just can't sleep soundly here because it's too noisy.' Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Reducing noise by keeping conversations and activities minimal at night directly addresses the client’s sleep issue, improving rest critical for eating disorder recovery. Habituation dismisses the concern, daytime sleep disrupts circadian rhythm, and TV adds new disturbances.
Question 4 of 5
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?
Correct Answer: C
Rationale: A client with bipolar disorder exhibiting poor impulse control presents an immediate safety concern. Poor impulse control can lead to risky behaviors, self-harm, or harm to others, necessitating an urgent update to the care plan with safety measures like close supervision or medication adjustments. Anorexia-related fear of weight gain requires monitoring but not immediate safety updates; tangential speech in schizophrenia is a symptom managed through ongoing care; and memory issues in Alzheimer’s, while distressing, don’t typically pose an immediate safety risk.
Question 5 of 5
A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Informing the client of their legal right to refuse treatment respects autonomy and empowers informed decision-making, addressing anxiety-related concerns. Encouragement may feel coercive, family consent is inappropriate unless the client is incompetent, and another nurse’s review doesn’t override refusal rights.