ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Informing the client of their right to refuse respects autonomy and addresses anxiety by empowering choice. Encouragement may coerce, family consent is inappropriate unless incompetent, and another nurse’s review doesn’t override refusal.
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: Bradycardia (44/min) is life-threatening in anorexia due to malnutrition, requiring immediate attention, followed by dehydration (skin turgor) to stabilize.
Extract:
Vital Signs
Admission, 1600:
Temperature: 36.1° C (97° F)
Blood pressure: 98/66 mm Hg
Heart rate: 76/min
Respiratory rate: 10/min
Pulse oximetry: 95% on room air
Diagnostic Results
Blood alcohol level (BAC): 310 mg/dL (0 to 50 mg/dL)
History & Physical
Neurological: Client is intoxicated, has slurred speech, and is unable to coherently respond to questions.
Cardiovascular: Normal sinus rhythm and pulses palpable. No history of heart disease.
Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders and client states they quit smoking over 20 years ago.
Gastrointestinal: Client reports weight loss over the past 3 months and minimal appetite.
Genitourinary: Client reports no known problems.
Impression: Relapse of alcohol use disorder.
Plan: Admit for alcohol use disorder and observe for alcohol withdrawal.
Nurses’ Notes
Client brought in by a family member who states that the client has been drinking “nonstop since the death of the client’s parents 3 months ago.”
Client has a history of alcohol use disorder for over 20 years.
Client attended an inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.
According to the client’s family member, the client has been unable to cope with the sudden death of their parents.
Client is currently unemployed after being laid off.
Client’s family member states, “Everything combined caused the drinking to start again.”
Family member estimates the client’s last drink was 2 hours ago.
Question 3 of 5
A nurse in a mental health facility is admitting a client.Exhibits:Complete the following sentence by using the lists of options. The client is at risk for developing ___ as evidenced by the client's ___.
Correct Answer: A,B
Rationale: The client’s history of heavy alcohol use increases withdrawal risk when intake stops, evidenced by prior consumption patterns.
Extract:
Nurse’s 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
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
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.)
Question 4 of 5
The nurse is continuing to care for the patient in the emergency department.Which findings should the nurse identify as potential complications of the client’s diagnostic results? Select all that apply.
Correct Answer: A,B,E,F
Rationale: GHB, suspected here, causes nausea/vomiting (
A), confusion (
B), amnesia (E), and respiratory depression (F) due to CNS depression. Tachycardia (
C) isn’t typical (bradycardia is), and hypothermia (
D) isn’t linked.
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 5 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: The client’s sadness and hopelessness, linked to parental loss and isolation, indicate a risk exacerbated by feeling powerless over life events.