ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Nurses’ Notes
2000:
Client presents to the triage desk accompanied by a friend. The client states, “I need help. I was raped about an hour ago.” The client’s friend states, “I think they may have been drugged.” Allergies: penicillin, doxycycline Physical exam: General: exhibits anxiety Respiratory: breath sounds clear Cardiovascular: S1, S2, no murmur Abdomen: soft, mildly tender Skin: bruising to upper arms bilaterally, broken fingernails
Vital Signs
2015:
Blood pressure: 128/88 mm Hg
Heart rate: 80/min
Respiratory rate: 16/min
Temperature: 37°C (98.6°F)
Weight: 67.1 kg (147.9 lbs.)
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
Question 1 of 5
A nurse is caring for a client in the emergency department.Drag words from the choices below to fill in each blank in the following sentence. The nurse should identify that the client’s ------------------------ and -------------------- are consistent with sexual assault.
Correct Answer: A,B
Rationale: GHB in diagnostic results and abdominal tenderness with bruising support sexual assault. Other vitals (BP, temp) are normal and less specific.
Extract:
Question 2 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Sensors (
B) alert caregivers to wandering, a mattress on the floor (
C) reduces fall injury, and high locks (E) prevent exits. A chair (
A) doesn’t address wandering and may harm, while bedtime activity (
D) may increase alertness, not sleep.
Question 3 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Sensors (
B), floor mattress (
C), and high locks (E) enhance safety against wandering and falls. A chair (
A) is impractical, and late activity (
D) may disrupt sleep.
Question 4 of 5
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Documenting the client's refusal of the treatment in the medical record is the correct action. It is essential to record the client's decision and the discussion surrounding it to respect their rights and provide a legal record. Even with involuntary commitment, clients retain the right to refuse treatment unless legally deemed incompetent or a danger, requiring specific legal processes. Asking family to encourage ECT doesn’t address autonomy, telling them they can’t refuse is incorrect, and stating ECT doesn’t need consent is unethical.
Question 5 of 5
A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?
Correct Answer: D
Rationale: A lack of sleep is a hallmark of acute mania, where clients feel little need for rest, exacerbating other symptoms. Detailed scheduling, refusal to converse, and isolation align more with depression or other states, not mania’s high energy.