ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Obtain a prescription for seclusion within 30 minutes. This is crucial as seclusion should be prescribed by a healthcare provider promptly to ensure it is appropriate and necessary for the client's safety. Keeping the client in seclusion for a specific time frame (choice
A) may not align with the client's individual needs. Monitoring vital signs (choice
C) and documenting behavior (choice
D) are important but not as time-sensitive as obtaining the prescription. It is essential to prioritize the client's immediate safety by following the appropriate protocols and obtaining the necessary authorization for seclusion promptly.
Extract:
2045
• X-ray of left wrist
• Hydrocodone 2.5 mg/acetaminophen 325 mg, 2 tablets PO now
2345:
• Discharge to home.
• Follow-up with orthopedist, their office will call tomorrow.
• Keep left arm elevated with splint on.
• Ice left wrist per written instructions provided.
• Ibuprofen 800 mg PO every 8 hr PRN pain
Medical History
• Premenstrual dysphoric disorder
• No known allergies
Physical Examination 2030
• Left wrist injury and edema
• Finger-shaped bruises on the left forearm
• Reports pain with movement of left wrist and hand as 8 on a 0 to 10 pain scale, and pain as 6 at rest. Grimacing and tearfulness noted with movement. Fingers warm with capillary refill less than 2 seconds.
2145:
• Reports left wrist pain as 6 with movement and as 4 at rest on a 0 to 10 pain scale.
Nurses’ Notes 2030
• Client presents for evaluation of left wrist injury reportedly following an incident of partner violence. The client states their partner had been drinking heavily prior to the physical altercation. The client reports the partner roughly grabbed their left arm while yelling loudly in their face. The client was able to free their arm and was walking to their car to leave when the partner aggressively pushed the client from behind. The client fell forward, using both arms to brace their fall. The client states the partner saw their wrist injury and began crying and apologizing, promising to never drink again. The client states, “I’ve heard that promise so many times, but they’ve never cried before, so I think it is sincere this time.”
• Left arm elevated on 2 pillows. Ice pack applied to left wrist.
2045:
• Provider in to see client. Prescriptions received.
2145:
• Client returned to room from radiology department via wheelchair. Left arm elevated and ice pack reapplied. A law enforcement officer in to talk with client after receiving a 911 call from the client’s neighbor who witnessed the physical altercation.
2330:
• Client declines to press charges against partner, per report of law enforcement officer. The client agreed to a social services referral, appointment scheduled for tomorrow. Discussed safety plan with client and the client reports having an envelope of important papers already hidden at home. Also provided the client with the phone numbers for the local crisis hotline and safe house. The client is receptive to information but states, “I need to work on my relationship a while longer. I really think things will get better this time.”
Question 2 of 5
A nurse in an emergency department is caring for a client who recently experienced partner violence.Exhibits:The nurse is reviewing the client’s medical record at discharge. For each finding, specify whether the finding indicates a potential improvement in or a worsening of the client’s physical or psychological status.
| Options | Indicates potential improvement | Indicates potential worsening |
|---|---|---|
| Client states that the partner will not be violent in the future. | ||
| Client agrees to an appointment with a social worker. | ||
| Client's reported pain level of the left wrist. | ||
| Client requests help developing a safety plan. | ||
| Client claims responsibility for the physical altercation. |
Correct Answer:
Rationale: [1, 0, 0]
Correct Answer: A: Client states that the partner will not be violent in the future.
Rationale: This indicates a potential improvement in the client's physical and psychological status as it suggests a commitment to a non-violent future.
Summary: B: Client agrees to an appointment with a social worker - While beneficial, it does not directly address future violence. C: Client's reported pain level of the left wrist - Focuses only on physical aspect. D: Client requests help developing a safety plan - Indicates awareness of potential danger but not future behavior. E: Client claims responsibility for the physical altercation - May not indicate a change in future violence.
Extract:
Question 3 of 5
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client's spiritual needs?
Correct Answer: D
Rationale: The correct answer is D. Offering to contact the client's spiritual advisor shows support for the client's spiritual needs, providing them with an opportunity to seek comfort and guidance from someone who shares their beliefs. This action respects the client's autonomy and individual preferences. It acknowledges the importance of spirituality in the grieving process, which can provide solace and coping mechanisms.
Options A, B, and C are incorrect:
A: Encouraging the client to internalize their feelings may hinder the grieving process and inhibit emotional expression, potentially leading to unresolved issues.
B: Changing the subject when the client expresses anger dismisses their emotions and prevents them from processing their feelings effectively.
C: Allowing the client to be alone during times of spiritual inadequacy may exacerbate feelings of isolation and hinder their ability to seek support and comfort.
Question 4 of 5
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Failure to recognize familiar objects. In Alzheimer's disease, individuals often experience difficulties with memory and cognitive function, leading to the inability to recognize familiar objects or people. This is due to the progressive deterioration of brain cells affecting memory and perception. Altered level of consciousness (
A) is not a typical finding in Alzheimer's disease unless there is a medical complication. Excessive motor activity (
C) is not commonly associated with Alzheimer's, as individuals often exhibit decreased motor skills. Rapid mood swings (
D) may occur in some cases, but failure to recognize familiar objects is a more characteristic finding.
Question 5 of 5
A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express their feelings. This is important because it allows the client to process their emotions, reduce feelings of isolation, and promote a sense of validation. By expressing their feelings, the client can better cope with anticipatory grief associated with dementia. Providing a timeline (choice
A) might not be helpful as grief is a unique process for each individual. Showing sympathy (choice
C) is important, but encouraging the client to express their feelings is more directly beneficial. Sharing personal stories (choice
D) can shift the focus away from the client's needs. The other choices are not relevant to addressing the client's emotional needs in this situation.