ATI RN
ATI RN Mental Health 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Focus the client on reality-based activities. This is important because redirecting the client's focus to reality-based activities can help ground them and reduce the intensity of hallucinations. By engaging in activities that connect them to the present moment, the client can gain a sense of control and stability.
Choice A is incorrect as denying the client's experience can lead to mistrust and distress.
Choice B is incorrect as avoiding direct questions may not address the client's needs effectively.
Choice D is incorrect as conveying sympathy alone may not provide the client with coping strategies.
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 2 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 3 of 5
A nurse is assessing the sleep pattern of a client who has an anxiety disorder. The client reports having difficulty sleeping most nights. Which of the following recommendations should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Exercise at least 3 hours before bedtime. Exercise helps reduce anxiety and promotes better sleep by releasing endorphins and reducing stress hormones. Exercising too close to bedtime can actually stimulate the body, making it harder to fall asleep.
Choice A is incorrect as watching television can be stimulating and disrupt sleep.
Choice C is incorrect as eating too close to bedtime can lead to indigestion and discomfort.
Choice D is incorrect as taking a long nap during the day can interfere with nighttime sleep.
Question 4 of 5
A nurse in an outpatient mental health facility is preparing to administer phenelzine to a client who has been taking this medication for several years. The client reports eating a grilled cheese sandwich and a banana for lunch and is feeling dizzy. Which of the following vital signs should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A: Blood pressure. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause hypertensive crisis if combined with foods high in tyramine, like cheese and bananas. Assessing blood pressure first is critical to monitor for any signs of hypertensive crisis, such as a sudden increase in blood pressure that could lead to serious complications. Respiration, pulse, and temperature are also important to assess, but blood pressure takes precedence in this situation due to the potential life-threatening effects of hypertensive crisis.
Question 5 of 5
A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when supporting the client's refusal of medications?
Correct Answer: A
Rationale: The correct answer is A: Autonomy. Autonomy refers to respecting the client's right to make their own decisions about their treatment. By supporting the client's refusal of medications, the nurse is upholding the principle of autonomy and acknowledging the client's right to choose what happens to their own body. This empowers the client and promotes self-determination.
Other choices are incorrect because:
B: Beneficence focuses on doing good for the client, which would involve ensuring the client receives necessary treatment.
C: Veracity relates to truth-telling, not the client's right to refuse treatment.
D: Justice is about fairness and equal treatment, not specifically related to respecting the client's autonomy.