ATI RN
ATI RN Mental Health 2019 NGN Questions
Extract:
Question 1 of 5
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 5
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Failure to recognize familiar objects. In Alzheimer's disease, individuals often have difficulty recognizing familiar objects due to cognitive decline. This is a hallmark symptom caused by brain changes affecting memory and perception. The other choices are incorrect because:
A) Altered level of consciousness is not typically a primary symptom of Alzheimer's disease.
B) Rapid mood swings may occur in some individuals with Alzheimer's, but it is not a definitive characteristic.
C) Excessive motor activity is not a common feature of Alzheimer's disease; rather, individuals may experience motor impairment as the disease progresses.
Question 3 of 5
A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?
Correct Answer: B
Rationale: The correct assessment the nurse should perform in this scenario is checking the client's blood pressure (
Choice
B). Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression, and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis due to the interaction between tyramine and MAOIs. Monitoring blood pressure is crucial to detect any hypertensive crisis early on. Assessing bowel sounds (
Choice
A), oxygen saturation (
Choice
C), and pupil response (
Choice
D) are not directly related to the potential hypertensive crisis caused by the interaction between phenelzine and tyramine.
Question 4 of 5
A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Have the provider assess the client within 1 hr after applying the restraints. This is the correct action to ensure the client's safety and well-being. Having the provider assess the client promptly allows for a comprehensive evaluation of the client's condition and the necessity of continued restraint use. This assessment is crucial to determine the client's mental status, physical well-being, and the appropriateness of ongoing restraint application.
Other choices are incorrect:
A: Requesting a renewal every 2 hours is excessive and may lead to unnecessary prolonged restraint use.
B: Hourly evaluation, while important, may not be sufficient to address potential changes in the client's condition that require immediate intervention.
D: Obtaining a prescription on an as-needed basis does not ensure timely assessment and may delay necessary intervention.
Question 5 of 5
A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect?
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
A: Bradycardia is common in anorexia nervosa due to malnutrition.
B: Russell's sign, calluses on knuckles from induced vomiting, is seen in bulimia but can occur in anorexia nervosa with purging behaviors.
C: Lanugo, fine hair growth on the body, is a sign of malnutrition in anorexia nervosa.
D: Hypotension can occur due to dehydration and malnutrition.
Incorrect answers:
E: Diarrhea is not typically associated with anorexia nervosa; constipation is more common.