ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Medical History and Physical Examination
Neurological: The client is intoxicated, has slurred speech, and is unable to respond coherently 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 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.
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
Nurse’s 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.” The family member estimates the client’s last drink was 2 hours ago. On Day 2 at 0800, the client is in the bathroom vomiting. The nurse assisted the client with oral and facial hygiene. The client states, “I feel awful.” The client is oriented, lethargic, and weak with visible hand shaking. The client reports they were up most of the night.
Diagnostic Results
Blood alcohol level (BAC): 310 mg/dL (0 to 50 mg/dL)
Question 1 of 5
A nurse is caring for a client who is experiencing alcohol withdrawal.Exhibits A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, specify if the potential prescription is anticipated or contraindicated for the client.
| Options | Anticipated | Contraindicated |
|---|---|---|
| Methadone 40 mg PO daily (Contraindicated) | ||
| Nutritional consult (Anticipated) | ||
| Perform AUDIT (Contraindicated) | ||
| Complete blood count and basic metabolic profile (Anticipated) | ||
| Group therapy (Anticipated) | ||
| Schedule ECT (Contraindicated) | ||
| Diazepam 10 mg PO three times a day (Anticipated) |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Methadone is contraindicated as it may worsen the client's condition due to its potential for respiratory depression.
- Nutritional consult is anticipated to address potential malnutrition and vitamin deficiencies common in alcohol use disorder.
- Performing AUDIT is contraindicated as it may not be appropriate during acute alcohol withdrawal.
- Complete blood count and basic metabolic profile are anticipated to assess for any alcohol-related complications.
- Group therapy is anticipated to provide social support and coping skills.
- Schedule ECT is contraindicated as it is not indicated for alcohol withdrawal.
- Diazepam is anticipated to manage alcohol withdrawal symptoms.
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 2 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: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: E, F.
Rationale: The correct actions are A (monitor for alcohol withdrawal symptoms) and B (assess history of alcohol consumption). The potential condition is seizures (
C) which can be a complication of alcohol withdrawal. Parameters to monitor are High Blood Alcohol Level (E) and Hallucinations (F) as indicators of alcohol-related issues. Unemployment (
D) is not directly related to alcohol withdrawal, making it incorrect.
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:A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.
Correct Answer: A,C,D,F,G
Rationale: The correct answers are A, C, D, F, and G. A gastrointestinal assessment is needed to monitor for any alcohol-related issues like GI bleeding. Blood alcohol level monitoring is crucial to assess intoxication levels. Recent loss can trigger alcohol use, requiring emotional support. Recent alcohol consumption indicates ongoing abuse. Neurological assessment is needed for potential alcohol-related brain damage. Smoking history and genitourinary assessment are not directly related to alcohol use disorder and do not require immediate follow-up in this scenario.
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 4 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 5 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