ATI RN
ATI RN Mental Health 2019 NGN Questions
Extract:
Question 1 of 4
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
Correct Answer: B
Rationale: The correct answer is B: The client's manifestations developed suddenly. Delirium is characterized by an acute onset of confusion, restlessness, and disorientation. This sudden change in behavior and cognitive function is a key indicator of delirium.
Choices A, C, and D are incorrect because a flat affect, inability to recognize objects, and slow and repetitious speech are not specific to delirium. Delirium is defined by its rapid onset and fluctuating nature, making choice B the most indicative finding in this scenario.
Question 2 of 4
A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?
Correct Answer: B
Rationale: The correct answer is B: Psychomotor retardation. This finding is the priority to report as it indicates a severe form of depression that can lead to physical and cognitive impairment, affecting the client's safety and ability to function. Psychomotor retardation is a significant risk factor for suicide and requires immediate attention. Significant weight loss (
A) is concerning but can be addressed through nutrition interventions. Markedly neglected hygiene (
C) can be a sign of self-neglect but does not pose an immediate risk. Poor problem-solving skills (
D) are common in depression but do not require urgent intervention compared to psychomotor retardation.
Question 3 of 4
A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Request that the client's guardian sign the consent. In cases where a client has been declared legally incompetent, their guardian is responsible for making decisions on their behalf. By having the guardian sign the consent form, the nurse ensures that the client's best interests are represented. Option A is incorrect because the social worker may not have legal authority to provide consent. Option B is incorrect as implied consent may not be sufficient in this scenario. Option D is incorrect as the charge nurse does not have the legal authority to obtain consent for a legally incompetent client.
Question 4 of 4
A nurse is assessing a client who has a history of substance use disorder and states, 'People are out to get me.' The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
Correct Answer: C
Rationale: The correct answer is C: Cocaine. The client's symptoms of paranoia, tachycardia, and hypertension are indicative of acute toxicity from cocaine. Cocaine can cause elevated heart rate and blood pressure, leading to tachycardia and hypertension. The client's paranoid beliefs also align with the known effects of cocaine, such as paranoia and hallucinations. Opium (
A) and heroin (
B) typically do not cause tachycardia and hypertension as prominently as cocaine. Alcohol (
D) may cause elevated heart rate and blood pressure in acute toxicity but is less likely to lead to paranoia and hallucinations compared to cocaine.
Question 5 of 4
A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role of monopolizer?
Correct Answer: B
Rationale: The correct answer is B, the adolescent daughter who attempts to dominate the discussion. This is because monopolizing behavior involves dominating conversations and not allowing others to express their thoughts or opinions. In this scenario, the daughter's behavior indicates a tendency to control the communication within the family, which can hinder effective dialogue and problem-solving.
A: The father intervening in sibling arguments does not necessarily indicate monopolizing behavior.
C: The son's refusal to share personal feelings may be a defense mechanism rather than monopolizing behavior.
D: The mother's hostility towards her spouse is a separate issue and does not directly relate to monopolizing communication.
In summary, the adolescent daughter's attempt to dominate the discussion aligns with the concept of monopolizing behavior, making her the correct choice in this scenario.