ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Provide environmental cues. Delirium can be triggered by environmental factors. Providing familiar cues, such as a clock or calendar, can help orient the client and decrease confusion, promoting safety. A: Promoting decision making may overwhelm the client. B: Discouraging visits can worsen feelings of disorientation. D: Physical restraints should be avoided as they can increase agitation and risk of injury.
Extract:
Medication Administration Record
• Escitalopram 20 mg once daily
Medical History
Client is 19 years old, has severe anxiety, and was admitted to an inpatient mental health facility for observation and behavioral therapy 2 weeks ago. The client’s weight at the time of admission was 54.4 kg (120 lb). The client reported sleeping 3 to 4 hours per night due to recurrent nightmares as well as a decrease in appetite. The client’s family member stated that the client had separated themselves from friends, refused to leave their house, and picked their skin until it bled. The client’s family member stated that there is a family history of anxiety. The client reported previous participation in cognitive-behavioral therapy.
Nurses’ Notes
Client appears to be well-groomed. The client’s current weight is 54 kg (119 lb). The client states they are sleeping 5 to 6 hours per night but having an occasional nightmare. The client verbalizes decreased appetite and gastrointestinal discomfort. The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.” The client verbalizes that bullying experienced during high school has led to anxiety. The client engages in thought-stopping behavioral therapy and cognitive restructuring. The client reports taking escitalopram 20 mg daily 2 hours after breakfast.
Question 2 of 5
A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility 1 week ago.Exhibits: A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect a finding, click on the finding again.
Correct Answer: A,C,E,F
Rationale: The correct answer is A, C, E, F. A: Well-groomed appearance indicates self-care and improvement in mood. C: Verbalizing decreased appetite and gastrointestinal discomfort may indicate decreased anxiety symptoms. E: Engaging in thought-stopping therapy and cognitive restructuring shows active participation in treatment. F: Taking prescribed medication as directed indicates compliance with the treatment plan. These findings suggest the client's condition is improving.
Choices B, D, and G do not indicate clear improvement in the client's condition. B: Occasional nightmares suggest ongoing sleep disturbances. D: Statement about anxiety leaving the house indicates ongoing anxiety symptoms. G: Past bullying experiences may contribute to the client's anxiety but do not directly indicate improvement in the current condition.
Extract:
Provider Prescriptions
• Olanzapine 10 mg tablet PO daily
• Alprazolam 1 mg tablet PO three times daily PRN anxiety
Nurses’ Notes
Client reports hearing voices that are talking about race cars and race tracks. Client appears diaphoretic and pale. Client reports weight gain of 2.2 kg (4.9 lb) in the past week.
Graphic Record
• BP 128/82 mmHg
• Pulse rate 98/min
• Respiratory rate 20/min
• Temperature 39.4° C (103° F)
• SaO2 95%
Question 3 of 5
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Correct Answer: A
Rationale: The correct answer is A: Temperature. The nurse should report temperature findings to the provider as it can indicate potential infection or other medical issues. Elevated temperature can be a sign of infection which could exacerbate the client's schizophrenia symptoms. Blood pressure (
B) and weight gain (
C) may be important but are not as urgent as temperature in this scenario. Hallucinations (
D) are a symptom of schizophrenia and should be addressed by the nurse but are not typically reported to the provider as they are expected in this client population.
Extract:
Provider’s Note
0230:
Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
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
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 assessment, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair.
0230:
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 their room, client voided 250 mL of dark yellow, cloudy urine.
Laboratory Results
0230:
Serum toxicology screen:
Alcohol 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Question 4 of 5
The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.Exhibits:For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
| Options | Delirium | Alzheimer’s Disease |
|---|---|---|
| Sudden onset of confusion | ||
| Hallucinations | ||
| Agitation | ||
| Current medical diagnosis |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Sudden onset of confusion is more indicative of delirium due to its acute and fluctuating nature.
- Hallucinations can be seen in both delirium and Alzheimer's but are more common in delirium.
- Agitation is a common symptom in delirium and can also occur in Alzheimer's.
- Current medical diagnosis should also be checked to understand the overall clinical picture.
-
Therefore, the correct answer selects all options as each finding can potentially support either delirium or Alzheimer's disease.
Extract:
Vital Signs
0200:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 104/min
o Respiratory rate: 18/min
o Blood pressure: 158/96 mm Hg
o Oxygen saturation: 98% on room air
0415:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 108/min
o Respiratory rate: 20/min
o Blood pressure: 148/94 mm Hg
o Oxygen saturation: 98% on room air
Nurses’ Notes
0205:
The client was brought to the ED by police after being found wandering on the street. The client was able to provide their identity to the police, but was not able to identify the place or time. The family was notified. The client appeared confused and agitated. Their appearance was disheveled. Their mucous membranes were dry. Their lungs were clear and equal, and their heart rhythm was regular. During the assessment, the client stated, “Can you ask that person to leave my room?” The client was pointing to an empty chair.
0230:
The client’s adult child arrived at the ED and went to the client’s room. The client identified the family member. The client was pacing and agitated, and stated, “I don’t understand why I am here.” The adult child asked the nurse to talk outside of the room and stated, “I don’t know why they are so confused. They are not normally like this.” The adult child stated that the client has a past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, the client voided 250 mL of dark yellow, cloudy urine.
0415:
The client was admitted to the medical-surgical unit. A peripheral IV was initiated in the right arm. The client was agitated, trying to pull out the IV, and yelling, “I am leaving now!”
Provider’s Note
0230: Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
0400: The client will be transferred to the medical-surgical unit.
Laboratory Results
0230: Serum toxicology screen: Alcohol 60 mg/dL (80 to 200 mg/dL indicates mild to moderate intoxication)
Question 5 of 5
The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.Exhibits:Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.
Correct Answer: B,D,E
Rationale: The correct answer is B, D, and E. Reorienting the client helps maintain their cognitive function. Approaching slowly minimizes agitation and builds trust. Maintaining a low-stimulation environment supports the client's well-being. A is incorrect as family support can be beneficial. C is unnecessary unless there are specific reasons.