ATI PN Mental health DEC 2023

Extract:

Question 1 of 5

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

A. Document the client’s behavior in the medical record every 1 hr B. Provide range-of-motion exercises to all extremities every 2 hr C. Request the provider renew the prescription in 24 hr D. Keep staff interactions with the client to a minimum

Correct Answer: B

Rationale: Range-of-motion exercises every 2 hours prevent stiffness and maintain circulation in restraints. A is excessive, C misaligns with reassessment needs, and D neglects monitoring.

Question 2 of 5

A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client’s medical record?

A. Timeout B. Restraint C. Diversion D. Therapeutic hold

Correct Answer: A

Rationale: A timeout allows the client to regain control in a safe space, a de-escalation technique. B and D are restrictive, and C is distraction, not de-escalation.

Question 3 of 5

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

A. I check my blood pressure once a week.' B. I chew sugar-free gum several times daily.' C. I haven’t had a drink of alcohol since I started taking these injections.' D. I spend several hours a day outside gardening when it’s sunny.'

Correct Answer: D

Rationale: Spending hours in the sun increases photosensitivity risk, a haloperidol side effect. A, B, and C are appropriate or harmless behaviors.

Question 4 of 5

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

A. Lower the window shade in the client’s room B. Obtain a PRN prescription for a vest restraint C. Place the client in a room close to the nurses’ station D. Request a consult with recreational therapy

Correct Answer: C

Rationale: Placing the client near the nurses’ station allows frequent monitoring to prevent falls. A doesn’t address falls, B is a last resort, and D is unrelated.

Question 5 of 5

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Your Answer:

Correct Answer: 2.5

Rationale: Calculation: 50 mg ÷ 20 mg/mL = 2.5 mL. This ensures the correct dose is administered based on the concentration available.

ATI PN Mental health DEC 2023 | Nurselytic

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ATI LPN

ATI LPN