ATI RN
ATI Mental Health 2023 II Questions
Extract:
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 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 hr ago.
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.
Question 1 of 4
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: B,C,D,E,F
Rationale:
Correct
Answer: B, C, D, E, F
Rationale:
B: Client's recent consumption of alcohol should be followed up as it indicates potential relapse or withdrawal symptoms.
C: Blood alcohol level should be monitored to assess intoxication level or withdrawal risk.
D: Client's recent loss may trigger emotional distress or exacerbate alcohol use disorder symptoms.
E: Respiratory assessment is crucial due to potential respiratory depression associated with alcohol use.
F: Neurological assessment is needed to evaluate cognitive function and potential alcohol-related neurological impairment.
Summary:
A: Smoking history is not directly related to immediate alcohol use disorder management.
G: Cardiac assessment is not a priority unless there are specific cardiac symptoms present.
Extract:
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 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 hr ago.
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.
Question 2 of 4
The client is at risk for developing ___ as evidenced by the client’s ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. Action A (Dysphoria): Addressing client's emotional distress is crucial in preventing further complications.
2. Action B (History of alcohol consumption): Identifying substance abuse history helps in personalized interventions.
3. Potential Condition C (Dementia): Client's cognitive impairment may exacerbate risks and require tailored care.
4. Parameter to Monitor D (Age): Age is a significant factor in assessing the client's overall health and potential risks.
5. Parameter to Monitor E (History of rehabilitation): Past rehabilitation experiences can influence current treatment effectiveness.
These choices are selected based on their direct relevance to the client's risk factors and individual characteristics.
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
Day 2, 0800:
Temperature 37.3° C (99.1° F)
Blood pressure 198/86 mm Hg
Heart rate 116/min
Respiratory rate 22/min
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 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 hr ago.
Day 2, 0800:
Client is in the bathroom vomiting. Assisted the client with oral feeding
Question 3 of 4
A nurse is caring for a client who is experiencing alcohol withdrawal.Exhibits:A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
| Options | Anticipated | Contraindicated |
|---|---|---|
| Group therapy | ||
| Nutritional consult | ||
| Propranolol 40 mg PO twice a day | ||
| Perform Alcohol Use Disorders Identification Test (AUDIT) | ||
| Schedule electroconvulsive therapy (ECT) | ||
| Diazepam 10 mg PO three times a day | ||
| Methadone 40 mg PO daily |
Correct Answer:
Rationale:
To determine the correct answer, we must consider the client's alcohol withdrawal symptoms and appropriate interventions. Group therapy is anticipated as it provides support. Nutritional consult (
B) is anticipated to address potential malnutrition. Propranolol (
C) is contraindicated in alcohol withdrawal due to risk of hypotension and masking of symptoms. AUDIT (
D) is anticipated for screening. ECT (E) is not indicated for alcohol withdrawal. Diazepam (F) may be considered for severe withdrawal symptoms. Methadone (G) is not indicated for alcohol withdrawal.
Therefore, the correct answer is (0, 1, 0, 1).
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
Day 2, 0800:
Temperature 37.3° C (99.1° F)
Blood pressure 198/86 mm Hg
Heart rate 116/min
Respiratory rate 22/min
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 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 hr ago.
Day 2, 0800:
Client is in the bathroom vomiting. Assisted the client with oral feeding.
Question 4 of 4
The nurse should first administer ___ followed by administering ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Nausea/Vomiting; Parameter to Monitor: Blood pressure, Heart rate.
Rationale: Metoclopramide is commonly used to treat nausea/vomiting, making it a suitable initial choice. Propranolol can be administered to manage symptoms of anxiety or tremors that may occur. Monitoring blood pressure and heart rate is crucial due to potential side effects of these medications on cardiovascular function. Methadone, a pain medication, is not appropriate for this scenario. Propanolol is misspelled and not relevant.
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
Day 2, 0800:
• Temperature 37.3° C (99.1° F)
• Blood pressure 198/86 mm Hg
• Heart rate 116/min
• Respiratory rate 22/min
Hospital day 5,0800:
• Temperature 36.1° C (97° F)
• Blood pressure 128/66 mm Hg
• Heart rate 74/min
• Respiratory rate 12/min
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 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 hr ago.
Day 2, 0800:
Client is in the bathroom vomiting. Assisted the client with oral feeding and he has a good appetite.
He resolves to limit his alcohol intake moving forward. He has currently accepted the news about his parents demise and is attending group therapy.
Question 5 of 4
A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.
Correct Answer: A,B,D,E
Rationale: The correct answer includes appetite, movement through stages of grief, participation in group therapy, and client resolving to limit alcohol consumption. These findings indicate progress as they show physical, emotional, social, and behavioral improvements. Monitoring appetite reflects physical well-being. Movement through grief stages indicates emotional healing. Participation in group therapy signifies social engagement. Resolving to limit alcohol consumption demonstrates behavioral change towards healthier choices.
Choices C and F-G are incorrect as cognition alone doesn't capture holistic progress, and the remaining options lack the diverse indicators of progress seen in the correct answer.