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 legal right to refuse treatment respects autonomy and empowers informed decision-making, addressing anxiety-related concerns. Encouragement may feel coercive, family consent is inappropriate unless the client is incompetent, and another nurse’s review doesn’t override refusal rights.
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 2 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:
Question 3 of 5
For which of the following adverse effects should a nurse monitor a client taking citalopram?
Correct Answer: B
Rationale: Decreased libido is a known adverse effect of citalopram, an SSRI. SSRIs can affect sexual function due to increased serotonin levels, leading to decreased libido, difficulty achieving orgasm, or erectile dysfunction. Urinary retention is not commonly linked to citalopram; bruising may occur rarely with bleeding risks but isn’t typical; and jaundice, indicating liver issues, is rare and not routine to monitor unless other risk factors are present.
Question 4 of 5
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?
Correct Answer: A
Rationale: Demonstrating orientation to person, place, and time suggests cognitive stability, indicating the client may no longer pose a risk, allowing restraint removal. Refusal of medication or threats of self-harm suggest ongoing risk, and following commands alone isn’t sufficient without broader assessment.
Question 5 of 5
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?
Correct Answer: C
Rationale: A client with bipolar disorder exhibiting poor impulse control presents an immediate safety concern. Poor impulse control can lead to risky behaviors, self-harm, or harm to others, necessitating an urgent update to the care plan with safety measures like close supervision or medication adjustments. Anorexia-related fear of weight gain requires monitoring but not immediate safety updates; tangential speech in schizophrenia is a symptom managed through ongoing care; and memory issues in Alzheimer’s, while distressing, don’t typically pose an immediate safety risk.