ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Nurses’ Notes
1100: Client is alert and oriented x 4. The client exhibits positive self-esteem. No negativity noted during conversation. Preparing client for discharge to partial-hospitalization program.
1230: Client requests a smoked turkey club sandwich for lunch. Education regarding medications provided.
Medical History
Client has a history of major depressive disorder.
Medication Administration Record
Selegiline 5 mg PO twice daily
Question 1 of 5
A nurse is caring for a client on an acute care mental health unit. Exhibits:The nurse is providing discharge education to the client about their medication. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.When educating the client about their medication, the nurse should teach the client that there is a risk for ___ due to ___.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Ingestion of tyramine; Parameter to Monitor: Hypertensive crisis, Nervous System Instability.
Rationale:
1. Action A: Hypertensive crisis - Tyramine-containing foods can interact with certain medications causing a hypertensive crisis.
2. Action B: Ingestion of tyramine - Educating the client on avoiding tyramine-rich foods to prevent hypertensive crisis.
3. Potential Condition: Ingestion of tyramine - Tyramine can lead to a hypertensive crisis when combined with specific medications.
4. Parameters to Monitor: Hypertensive crisis, Nervous System Instability - Monitoring blood pressure for hypertensive crisis and signs of nervous system instability for adverse effects.
Extract:
Physical Examination
• Height: 152.4 cm (60 in)
• Weight: 36.7 kg (81 lb)
• BMI: 15.8
• Lanugo
• Decreased skin turgor
• Cold extremities
• Russell’s sign
• Hair loss
• Erosion of teeth enamel
• Client report of constipation
Vital Signs
• Heart rate: 44/min
• Respiratory rate: 20/min
• BP: 86/50 mm Hg
• Temperature: 36.2° C (97.2° F)
Medical History
The client is 18 years old and is being admitted into the inpatient eating disorder clinic. The client has had a history of anorexia nervosa since age 16. BMI has fluctuated from 15 to 19 over the past 3 years. The client reports restricting caloric intake to 400 cal/day, fasting, and dieting. The client also reports frequent episodes of binge eating, self-induced vomiting, frequent laxative use, and exercising three times per day, every day. The client states, “I am so fat. No matter what I do, I can’t get skinny or lose enough weight.” The client’s guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
Question 2 of 5
A nurse is initiating the plan of care for a client who has anorexia nervosa.Exhibits:Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. The nurse should first address the client's heart rate as an essential vital sign to assess the client's overall physiological status and potential cardiac complications related to anorexia nervosa.
2. Following that, monitoring the client's skin turgor is crucial as it indicates hydration status and can help assess the severity of malnutrition and dehydration.
3. Lanugo (fine hair growth) is a potential condition seen in clients with anorexia nervosa due to malnutrition and low body fat.
4. Monitoring heart rate continuously is important as it can indicate cardiac complications and the impact of malnutrition.
5. Hair loss is another parameter to monitor as it can be a sign of malnutrition and can provide insights into the client's nutritional status.
Summary:
Addressing heart rate and skin turgor first is crucial for assessing overall health status and hydration levels. Lanugo is
Extract:
Medical History
A 21-year-old client was brought to the emergency department by their college friend. The friend reports that the client has been in their room for a week and has not bathed or attended class for one week. Current medications include venlafaxine 150 mg daily. The client denies the use of over-the-counter and herbal medications but has thought about starting St. John’s Wort to help with symptoms.
Nurses’ Notes
0800: The client is dressed in wrinkled sweatpants, a stained t-shirt, and is sitting alone at breakfast. The client ate one bite of toast. The client makes no eye contact, stands up slowly, and asks to go back to the room to sleep.
0945: The client is out in the day room after sleeping for 1 hour. The client is walking with their head down. The client reports having no interest in classes or contacting friends and states, “I just feel so sad and hopeless right now.” The client lost their parents in a car accident at age 18 and fell into a deep depression. The client tried therapy and an antidepressant and found the interventions effective.
Question 3 of 5
A behavioral health unit nurse is caring for a newly admitted client.Exhibits:Complete the following sentence by using the lists of options: The client demonstrates risk for ___ due to ___.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: -; Parameter to Monitor: D, E.
Rationale:
- Feelings of hopelessness and powerlessness are common in clients at risk for self-harm, as they may feel overwhelmed and lack control. Monitoring self-harm behaviors and sleep disturbances (insomnia) can help assess the client's safety and mental well-being. Inadequate nutrition is not directly related to the client's risk for self-harm. The inclusion of "hopelessness" as a parameter to monitor is redundant since it is already mentioned in the correct actions to take.
Extract:
Question 4 of 5
For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?
Correct Answer: D
Rationale: The correct answer is D because a nurse is mandated to report any suspicion of child abuse or neglect, such as the partner tying the child to a bed. This falls under the category of child maltreatment, which must be reported to the appropriate agency to ensure the safety and well-being of the child.
Choices A, B, and C do not involve immediate harm to a vulnerable individual and do not fall under the mandated reporting requirements for nurses.
Question 5 of 5
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Identify prior coping skills. This should be the first action because understanding the adolescents' coping mechanisms will help tailor the crisis intervention effectively. By knowing their prior coping skills, the nurse can build on what has worked well for them in the past. This approach is client-centered and empowers the adolescents to utilize their strengths during this difficult time. Reviewing community resources (
B) can come later once the immediate needs are addressed. Discussing confidentiality (
C) is important but not the priority in a crisis situation. Initiating referrals (
D) may be necessary eventually but should follow understanding the adolescents' coping skills to ensure appropriate referrals are made.