ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 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: The correct answer is C. A client with bipolar disorder exhibiting poor impulse control poses a safety risk due to potential impulsive behaviors like self-harm or harm to others. Updating the plan of care to address impulse control can prevent crises. Clients in options A, B, and D also have significant needs, but they do not pose an immediate safety risk like poor impulse control. Option A's fear of gaining weight may need intervention, but it does not directly threaten safety. Option B's tangential associations may indicate a need for medication adjustment but do not pose an imminent safety risk. Option D's memory issues in Alzheimer's may require support but do not directly impact safety.
Extract:
Physical Examination
• Height: 152.4 cm (60 in)
• Weight: 36.7 kg (81 lb)
• BMI: 15.8
• Lanugo
• Decreased skin turgor
• Cold extremities
• Russell’s sign
• Hair loss
• Erosion of teeth enamel
• Client report of constipation
Vital Signs
• Heart rate: 44/min
• Respiratory rate: 20/min
• BP: 86/50 mm Hg
• Temperature: 36.2° C (97.2° F)
Medical History
The client is 18 years old and is being admitted into the inpatient eating disorder clinic. The client has had a history of anorexia nervosa since age 16. BMI has fluctuated from 15 to 19 over the past 3 years. The client reports restricting caloric intake to 400 cal/day, fasting, and dieting. The client also reports frequent episodes of binge eating, self-induced vomiting, frequent laxative use, and exercising three times per day, every day. The client states, “I am so fat. No matter what I do, I can’t get skinny or lose enough weight.” The client’s guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
Question 2 of 5
A nurse is initiating the plan of care for a client who has anorexia nervosa.Exhibits:Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. The nurse should first address the client's heart rate as an essential vital sign to assess the client's overall physiological status and potential cardiac complications related to anorexia nervosa.
2. Following that, monitoring the client's skin turgor is crucial as it indicates hydration status and can help assess the severity of malnutrition and dehydration.
3. Lanugo (fine hair growth) is a potential condition seen in clients with anorexia nervosa due to malnutrition and low body fat.
4. Monitoring heart rate continuously is important as it can indicate cardiac complications and the impact of malnutrition.
5. Hair loss is another parameter to monitor as it can be a sign of malnutrition and can provide insights into the client's nutritional status.
Summary:
Addressing heart rate and skin turgor first is crucial for assessing overall health status and hydration levels. Lanugo is
Extract:
Question 3 of 5
For which of the following adverse effects should a nurse monitor a client taking citalopram?
Correct Answer: B
Rationale: The correct answer is B: Decreased libido. Citalopram, a selective serotonin reuptake inhibitor (SSRI), can cause sexual side effects such as decreased libido. The rationale is that SSRIs can affect serotonin levels, which in turn can impact sexual function. Urinary retention (
A) is not a common side effect of citalopram. Bruising (
C) is not typically associated with this medication. Jaundice (
D) is a rare side effect of citalopram and would not be the primary concern when monitoring a client taking this medication. Monitoring for decreased libido is important to address potential side effects that may affect the client's quality of life.
Question 4 of 5
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Rationale:
Choice C is correct because the nurse should respect the client's autonomy and right to refuse treatment. By documenting the client's refusal in the medical record, the nurse ensures transparency and upholds the client's right to make decisions about their care. This also helps in ensuring that the healthcare team is aware of the client's preferences and can explore alternative treatment options if needed.
Incorrect
Choices:
A: Involving the client's family without consent disregards the client's autonomy.
B: Coercing the client by stating they cannot refuse is a violation of their rights.
D: Misinforming the client about consent for ECT is unethical and lacks transparency.
Question 5 of 5
A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B: "I will use the coping mechanisms that helped me in the past." This response indicates understanding as it shows the client's awareness of their previous successful strategies for managing depressive symptoms. By recognizing the effectiveness of past coping mechanisms, the client demonstrates an understanding of self-care and the importance of utilizing proven strategies.
Summary of other choices:
A: "I will stay in bed on days when I feel exhausted." - This choice reflects a passive and potentially maladaptive behavior that may worsen depression symptoms.
C: "I will avoid talking about events that upset me." - Avoidance can lead to suppression of emotions and hinder the client's ability to address underlying issues.
D: "I will rely on my partner to plan out my schedule each day." - This choice indicates dependence on others rather than promoting self-reliance and self-care behaviors.