ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?
Correct Answer: C
Rationale: The correct answer is C: The client will attend to personal hygiene. This outcome is important in the treatment of borderline personality disorder as it can improve the client's self-esteem and overall well-being. Personal hygiene is a fundamental aspect of self-care and can help the client feel more in control and confident. It also promotes a sense of normalcy and routine, which can be beneficial in managing symptoms of the disorder.
The other choices are incorrect because:
A: Verbalizing an improved mood may not directly address the core issues of borderline personality disorder.
B: Decrease in hallucinations is more commonly associated with psychotic disorders, not borderline personality disorder.
D: Communicating needs is important, but attending to personal hygiene is more fundamental for daily functioning.
E, F, G: Not provided in the question.
Extract:
Provider Prescriptions
Olanzapine 10 mg tablet, taken orally daily.
Alprazolam 1 mg tablet, taken orally three times daily as needed for anxiety.
Nurses’ Notes
The client reports hearing voices that are discussing race cars and race tracks. The client appears diaphoretic and pale. The client also reports a weight gain of 2.2 kg (4.9 lb) in the past week.
Graphic Record
Blood Pressure (BP): 128/82 mm Hg
Pulse Rate: 98/min
Respiratory Rate: 20/min
Temperature: 39.4° C (103° F)
Oxygen Saturation (SaO2): 95%
Question 2 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: B
Rationale:
Step 1: The nurse should report the client's temperature to the provider because it could indicate a potential infection or other physical health issue.
Step 2: Changes in temperature can impact overall health and may require medical intervention.
Step 3: Hallucinations are common in schizophrenia and may not necessarily require immediate medical attention.
Summary: Weight gain and blood pressure can be side effects of medications used to treat schizophrenia. Hallucinations are a common symptom of the disorder and may not always be alarming. Temperature, however, is a vital sign that can indicate a physical health concern requiring prompt attention.
Extract:
Question 3 of 5
A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?
Correct Answer: B
Rationale: The correct answer is B: Establish confidentiality guidelines with the client. This is the first step in building a trustful nurse-client relationship, especially in mental health settings where privacy is crucial. By setting clear confidentiality guidelines, the nurse ensures the client's information is kept confidential, fostering a sense of safety and trust. This initial step lays the foundation for open communication and collaboration between the nurse and the client.
Choice A is incorrect because assisting the client with coping strategies comes after establishing trust and confidentiality.
Choice C is incorrect as helping the client make behavioral changes is a later stage in the therapeutic process.
Choice D is incorrect because sharing information about the disorder should come after the trust has been established and confidentiality guidelines have been discussed.
Extract:
Nurses’ Notes
The client was 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. The client has a history of alcohol use disorder for over 20 years. The 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. The client is currently unemployed after being laid off. The client’s family member states, “Everything combined caused the drinking to start again.”
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
Day 2, 0800:
Temperature: 37.3 °C (99.1° F)
Blood pressure: 198/86 mm Hg
Heart rate: 116/min
Respiratory rate: 22/min
Hospital day 5, 0800:
Temperature: 36.1 °C (97° F)
Blood pressure: 128/66 mm Hg
Heart rate: 74/min
Respiratory rate: 12/min
Pulse oximetry: 96% on room air
Diagnostic Results
Blood alcohol level (BAC): 310 mg/dL (normal range: 0 to 50 mg/dL)
History & Physical
Neurological: The client is intoxicated, has slurred speech, and is unable to coherently respond to questions.
Cardiovascular: Normal sinus rhythm and pulses are palpable. No history of heart disease.
Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders, and the client states they quit smoking over 20 years ago.
Gastrointestinal: The client reports weight loss over the past 3 months and minimal appetite.
Genitourinary: The client reports no known problems.
Impression: Relapse of alcohol use disorder.
Plan: Admit for alcohol use disorder and observe for alcohol withdrawal.
Provider Prescriptions
Perform Alcohol Use Disorders Identification Test (AUDIT).
Complete blood count.
Basic metabolic profile.
Nutrition consultation.
Consult counselor for grief therapy.
Substance use group therapy.
Diazepam 10 mg PO three times a day.
Propranolol 40 mg PO twice a day.
Metoclopramide 10 mg IM every 6 hr PRN nausea and/or vomiting.
Question 4 of 5
A nurse is reviewing the day 5 vital signs.Exhibits:A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.
Correct Answer: A, B, D, E
Rationale:
Correct Answer: A, B, D, E
Rationale:
A: Vital signs - Monitoring vital signs helps assess the client's physiological response to treatment. Stable vital signs indicate progress.
B: Movement through stages of grief - Progression through grief stages signifies emotional healing and adaptation to treatment.
D: Participation in group therapy - Active participation in therapy shows engagement and willingness to work on recovery.
E: Appetite - Improved appetite suggests physical improvement and response to treatment.
Incorrect
Choices:
C: Cognition - Although important, cognition alone may not always directly indicate progress in response to treatment.
F: The client resolves to limit alcohol consumption - While important for health, this choice does not directly reflect progress in response to treatment.
Extract:
Question 5 of 5
A nurse is caring for a client who states, 'I have been having trouble sleeping for the last several months.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale:
Correct Answer:
A) "You should avoid stressful activities prior to going to sleep."
Rationale:
1. Stressful activities can increase arousal, making it difficult to fall asleep.
2. Avoiding stressors before bed can help the client relax and prepare for sleep.
3. Engaging in calming activities promotes a restful sleep environment.
4. This response addresses the client's sleep issue by suggesting a practical solution.
Summary of Incorrect
Choices:
B) Exercising close to bedtime can increase alertness, making it harder to fall asleep.
C) Taking a nap in the afternoon can disrupt the client's ability to sleep at night.
D) Watching TV in bed can stimulate the brain, making it challenging to unwind and sleep.