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: 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.
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 2 of 5
A nurse in a mental health facility is admitting a client.Exhibits:Complete the following sentence by using the lists of options. The client is at risk for developing ___ as evidenced by the client's ___.
Correct Answer: A,B
Rationale: The client’s history of heavy alcohol use increases withdrawal risk when intake stops, evidenced by prior consumption patterns.
Extract:
Nurse’s Notes
2000:
Client presents to the triage desk accompanied by a friend. The client states, “I need help. I was raped about an hour ago.” The client’s friend states, “I think they may have been drugged.” Allergies: penicillin, doxycycline Physical exam: General: exhibits anxiety Respiratory: breath sounds clear Cardiovascular: S1, S2, no murmur Abdomen: soft, mildly tender Skin: bruising to upper arms bilaterally, broken fingernails
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
Vital signs
2015:
Blood pressure: 128/88 mm Hg
Heart rate: 80/min
Respiratory rate: 16/min
Temperature: 37°C (98.6°F)
Weight: 67.1 kg (147.9 lbs.)
Question 3 of 5
The nurse is continuing to care for the patient in the emergency department.Which findings should the nurse identify as potential complications of the client’s diagnostic results? Select all that apply.
Correct Answer: A,B,E,F
Rationale: GHB, suspected here, causes nausea/vomiting (
A), confusion (
B), amnesia (E), and respiratory depression (F) due to CNS depression. Tachycardia (
C) isn’t typical (bradycardia is), and hypothermia (
D) isn’t linked.
Extract:
Question 4 of 5
A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?
Correct Answer: A
Rationale: Initiating social interactions is an appropriate, measurable outcome for autism spectrum disorder, targeting core deficits in communication and social skills. Delusions are unrelated to autism, peer pressure isn’t a specific goal, and meeting needs without manipulation is too broad and not autism-specific.
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 right to refuse respects autonomy and addresses anxiety by empowering choice. Encouragement may coerce, family consent is inappropriate unless incompetent, and another nurse’s review doesn’t override refusal.