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.
Extract:
Nurses' Notes
Admission: Client restless during the night, attempting to get out of bed and placing bedcovers on the floor. Has been incontinent of urine twice. Client instructed on use of urinal and told to call for assistance by using the call light. Confuses the call light with the television remote control. Disoriented to time, place, person, and situation. Unable to recall home address. Was unable to assist with bath this morning; when handed the washcloth to clean their face, client asked, "Do you want me to put this in the dryer?"
Medical History
A 76-year-old client fell at home, resulting in fractured humerus and multiple abrasions to arms. Client is unable to recall what precipitated the fall, and physical examination reveals no injury to the client's head. Client has a history of hypertension controlled with atenolol. Client lives with partner and adult children visit client every few months.
Question 2 of 5
A nurse is caring for a 76-year-old female client who experienced a fall.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
Correct Answer: B
Rationale: Alzheimer’s explains chronic confusion and task difficulty. Using symbols aids navigation, donepezil manages symptoms, and monitoring agnosia and familiar tasks tracks progression.
Extract:
Nurses' Notes
0800: Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in client's behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day. Intake and output from previous day: 250 mL intake, 2,500 mL output. Call placed to provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per provider's prescription. Client continues to be restless.
Vital Signs
• Heart rate: 115/min
• Respiratory rate: 20/min
• Blood pressure: 90/65 mm Hg
• Temperature: 38.6°C (101.5°F)
Question 3 of 5
A nurse is caring for an older adult client who is postoperative.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 arameters the nurse should monitor to collect data about the client's progress.
Correct Answer: A
Rationale: Delirium fits acute postoperative confusion. Family presence reassures, fluid monitoring addresses dehydration, and tracking fall risk and sleep assess safety and recovery.
Extract:
Question 4 of 5
A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?
Correct Answer: B
Rationale: Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options. This step is foundational, preceding the use of support networks, spirituality, or medication.
Question 5 of 5
A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: Haloperidol can increase photosensitivity, causing the skin to be more sensitive to sunlight, potentially leading to sunburn. Patients should be advised to use sunscreen and wear protective clothing. This statement shows the client understands a key side effect.