ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is in physical restraints. Which of the following actions by the client indicates the restraints can be discontinued?
Correct Answer: B
Rationale: The correct answer is B: The client remains in control of their actions. This indicates that the client is no longer a danger to themselves or others and can be safely removed from restraints. Apologizing (
A) does not necessarily indicate safety. Asking to be released (
C) may not reflect improved behavior. Signing a contract (
D) does not ensure current safety.
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 2 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:
Question 3 of 5
A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?
Correct Answer: C
Rationale: The correct answer is C: Improvement in manifestations of depression. Electroconvulsive therapy is primarily used to treat severe depression.
Therefore, improvement in depressive symptoms indicates the treatment's effectiveness. Reduced frequency of seizures (
A) is not relevant to ECT. Reduced panic attacks (
B) and decreased fear of heights (
D) are not direct indications of ECT effectiveness. Make sure to monitor for potential side effects of ECT such as memory problems.
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: D
Rationale: The correct answer is D. When the client is able to follow commands, it indicates that they have regained control and are not a danger to themselves or others. This criterion ensures the safe removal of physical restraints.
Choice A is incorrect as orientation alone does not guarantee the client's safety.
Choice B is incorrect because medication refusal does not necessarily indicate safety.
Choice C is incorrect as the client's verbal threat of harm is not a reliable indicator of their actual intentions.
Question 5 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: The correct answer is A: The client demonstrates that they are oriented to person, place, and time. This indicates the client's mental status and ability to make informed decisions. Removing restraints when the client is oriented helps ensure their safety and autonomy.
Choice B is incorrect as refusal of medication is not necessarily a reason to remove restraints.
Choice C is incorrect as self-harm risk does not automatically mean restraints should be removed.
Choice D is incorrect as following commands does not indicate the client's cognitive functioning or orientation level.