ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?
Correct Answer: D
Rationale: The correct answer is D: Improvement in manifestations of depression. Electroconvulsive therapy is primarily used to treat severe depression. Improvement in depressive symptoms indicates the treatment is effective. Decreased fear of heights (
A) is not a typical outcome of ECT. ECT is not used to treat seizures (
B). ECT may not directly target symptoms of borderline personality disorder (
C).
Extract:
Vital Signs
0200:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 104/min
o Respiratory rate: 18/min
o Blood pressure: 158/96 mm Hg
o Oxygen saturation: 98% on room air
0415:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 108/min
o Respiratory rate: 20/min
o Blood pressure: 148/94 mm Hg
o Oxygen saturation: 98% on room air
Nurses’ Notes
0205:
The client was brought to the ED by police after being found wandering on the street. The client was able to provide their identity to the police, but was not able to identify the place or time. The family was notified. The client appeared confused and agitated. Their appearance was disheveled. Their mucous membranes were dry. Their lungs were clear and equal, and their heart rhythm was regular. During the assessment, the client stated, “Can you ask that person to leave my room?” The client was pointing to an empty chair.
0230:
The client’s adult child arrived at the ED and went to the client’s room. The client identified the family member. The client was pacing and agitated, and stated, “I don’t understand why I am here.” The adult child asked the nurse to talk outside of the room and stated, “I don’t know why they are so confused. They are not normally like this.” The adult child stated that the client has a past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, the client voided 250 mL of dark yellow, cloudy urine.
0415:
The client was admitted to the medical-surgical unit. A peripheral IV was initiated in the right arm. The client was agitated, trying to pull out the IV, and yelling, “I am leaving now!”
Provider’s Note
0230: Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
0400: The client will be transferred to the medical-surgical unit.
Laboratory Results
0230: Serum toxicology screen: Alcohol 60 mg/dL (80 to 200 mg/dL indicates mild to moderate intoxication)
Question 2 of 5
The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.Exhibits:Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.
Correct Answer: B,D,E
Rationale: The correct answer is B, D, and E. Reorienting the client helps maintain their cognitive function. Approaching slowly minimizes agitation and builds trust. Maintaining a low-stimulation environment supports the client's well-being. A is incorrect as family support can be beneficial. C is unnecessary unless there are specific reasons.
Extract:
Question 3 of 5
A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Implement measures to prevent intentional self-inflicted injury. This is the priority because individuals with borderline personality disorder are at a high risk of self-harm or suicide. By focusing on preventing self-inflicted harm, the nurse ensures the client's safety and addresses the most immediate threat. Encouraging support group attendance (
A) and discussing assertive behavior (
B) are important but not as critical as safety. Assisting the client in maintaining awareness of thoughts and feelings (
D) is valuable for therapy but does not address the immediate risk of harm.
Question 4 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: C
Rationale: The correct answer is C: Obtain a prescription for seclusion within 30 minutes. This action is crucial as seclusion should only be implemented with a physician's order to ensure the client's safety and rights are protected. The nurse must promptly obtain this order to ensure the client's needs are met in a timely manner.
Choice A is incorrect because documenting the client's behavior every 60 minutes does not address the immediate need for a physician's order for seclusion.
Choice B is incorrect as there is no specific time limit for seclusion, and it should only be ended with a physician's approval.
Choice D is incorrect as monitoring vital signs every 4 hours is important but not as urgent as obtaining the seclusion prescription.
Question 5 of 5
A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain to the client that the duration of grief is highly variable and can last for years. This is important because grief is a complex and individual process that can take a significant amount of time to work through. By providing this information, the nurse can help the client understand that feeling depressed after 9 months is not uncommon and that it is okay to take the time needed to heal.
Choice A is incorrect because recommending more solitary activities may further isolate the client, exacerbating feelings of depression.
Choice C is incorrect as avoiding discussing the events surrounding the sibling's death may hinder the client's ability to process their grief.
Choice D is incorrect as cautioning the client against feeling angry at the sibling may invalidate the client's emotions.