ATI LPN
ATI LPN Mental Health 2023 II Questions
Extract:
Nurses' Notes
0205: Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified. Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular. During data collection, client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
0415: Client's adult child arrived to the ED and went to client's room. Client identified family member. Client is pacing and agitated, and states, "I don't understand why I am here." Adult child asks nurse to talk outside of room and states, "I don't know why they are so confused. They are not normally like this." Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Question 1 of 5
A nurse is caring for a 65-year-old male client in the emergency department (ED).For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
| Options | Expected | Unexpected |
|---|---|---|
| Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion. | ||
| Administer lorazepam. | ||
| Initiate 1:1 supervision. | ||
| Administer acyclovir. |
Correct Answer: A,B,C
Rationale: IV fluids address dehydration, lorazepam manages agitation or withdrawal, and 1:1 supervision ensures safety due to delirium. Acyclovir is unexpected as no viral infection is indicated.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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