ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?
Correct Answer: D
Rationale:
Correct
Answer: D - Reports a lack of sleep
Rationale:
1. Lack of sleep is a hallmark symptom of acute mania in bipolar disorder.
2. During acute mania, individuals often experience reduced need for sleep or insomnia.
3. This symptom can lead to increased energy levels, impulsivity, and agitation.
4. The nurse should prioritize addressing the client's sleep disturbance to prevent exacerbation of manic symptoms.
Other
Choices:
A: Writing a detailed daily activity schedule is not necessarily indicative of acute mania. It could be a coping mechanism or part of a structured routine.
B: Refusing to engage in conversation may suggest social withdrawal, but it is not specific to acute mania.
C: Isolating oneself from others can be a sign of depression or anxiety, but it does not directly indicate acute mania.
Question 2 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale: The correct instructions are B, C, and E. Installing sensor devices on outside doors helps prevent wandering. Positioning the mattress on the floor reduces fall risk. Putting locks at the top of doors prevents the client from wandering. Placing the client in a reclining chair does not address the wandering issue. Encouraging physical activity prior to bedtime may increase agitation and worsen wandering.
Question 3 of 5
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C. Reporting eating twice in the past week is a critical finding to report because it indicates a significant decrease in nutritional intake, which can lead to serious health complications. This is particularly concerning in the context of mania, as individuals experiencing manic episodes may neglect self-care, including eating regularly. In contrast, choices A, B, and D are all common behaviors associated with mania but do not pose an immediate threat to the client's physical health.
Choice A may indicate a hygiene issue, choice B is a symptom of pressured speech often seen in mania, and choice D reflects disinhibition commonly observed in manic states. However, these behaviors do not directly jeopardize the client's well-being in the same way as severe nutritional deprivation.
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 4 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: The correct answer choices (A, B, E, F) are potential complications of the client's diagnostic results in the emergency department. Nausea and vomiting (
A) can indicate an adverse reaction to medication or underlying condition. Confusion (
B) may result from electrolyte imbalances or neurological issues. Amnesia (E) could be a sign of mental status changes due to the diagnostic results. Respiratory depression (F) might indicate a worsening respiratory condition.
Choices C and D are unlikely complications related to diagnostic results, as tachycardia (
C) is more likely a physiological response to stress or pain, while hypothermia (
D) is not typically associated with diagnostic tests.
Extract:
Nurses’ 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
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.)
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
Question 5 of 5
A nurse is caring for a client in the emergency department.Drag words from the choices below to fill in each blank in the following sentence. The nurse should identify that the client’s ------------------------ and -------------------- are consistent with sexual assault.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Sexual assault; Parameter to Monitor: D, E.
Rationale:
1. The nurse should review diagnostic results (Action
A) to identify any physical evidence of sexual assault.
2. Conducting an abdominal examination (Action
B) can reveal signs of trauma or injury related to sexual assault.
3. Sexual assault is the potential condition (
C) the nurse should consider based on the client's presentation.
4. Monitoring the client's temperature (Parameter
D) is important to detect any signs of infection or hypothermia post-assault.
5. Monitoring drug assessment (Parameter E) is crucial to assess for any substances or drugs involved in the assault.