ATI RN
ATI RN Mental Health 2023 III Questions
Extract:
Question 1 of 5
A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Monitor the child's vital signs every 15 minutes. This action is essential to ensure the child's safety while in restraints. Monitoring vital signs helps the nurse assess the child's physiological response to the restraints, such as changes in heart rate, blood pressure, and respiratory rate. This allows for early detection of any complications or distress, enabling prompt intervention if necessary. It is crucial to closely monitor vital signs in this situation to prevent any adverse outcomes related to the use of physical restraints. Keeping the restraints on for a minimum of 1 hour (
A) is not appropriate as the duration should be based on the child's behavior and safety. Asking the provider to renew the prescription for the restraints every 24 hours (
C) is important but not the immediate priority. Arranging an in-person evaluation by the child's provider within 2 hours of initiating restraints (
D) is also important, but monitoring vital signs is the more immediate and critical action
Question 2 of 5
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Offer the client the medication at the next scheduled dose time. This option respects the client's autonomy and right to refuse treatment, while also ensuring that the client receives the necessary medication. By offering the medication at the next scheduled time, the nurse can continue to monitor the client's condition and provide support without resorting to coercive measures.
Option B: Implement consequences until the client takes the medication, is incorrect as it goes against the client's right to refuse treatment and may damage the therapeutic relationship.
Option C: Inform the client that he does not have the right to refuse the medication, is incorrect as it disregards the client's autonomy and can lead to further resistance to treatment.
Option D: Administer the medication to the client via IM injection, is incorrect as it violates the client's right to make informed decisions about their treatment. This approach should only be considered in emergency situations where the client's safety is at risk.
Question 3 of 5
A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?
Correct Answer: B
Rationale: The correct answer is B: A translator of the same gender as the client. This choice is the most appropriate because it ensures effective communication while also considering the client's comfort and cultural sensitivity. The translator will help bridge the language barrier, ensuring accurate understanding and expression of thoughts and feelings. Choosing a translator of the same gender can further enhance the client's comfort level and promote trust within the group. This option prioritizes clear communication and respects the client's needs.
Choice A is not ideal as the unit secretary may not have the necessary language proficiency for effective communication.
Choice C, another client, may not be reliable or appropriate for maintaining confidentiality.
Choice D, a family member, could introduce potential conflicts of interest and may not be impartial.
Question 4 of 5
A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?
Correct Answer: B
Rationale: The correct answer is B: Blood glucose 256 mg/dL (74 to 106 mg/dL). The nurse should notify the provider because this finding indicates hyperglycemia, a potential side effect of risperidone. Risperidone can lead to metabolic changes, including increased blood glucose levels. Hyperglycemia is a serious concern as it can lead to complications such as diabetic ketoacidosis.
Therefore, prompt notification to the provider is crucial for further evaluation and management.
Other choices are within the normal ranges or close to the normal values for WBC count, sodium, and platelets, which do not require immediate provider notification.
Question 5 of 5
A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Explain to the client that the duration of grief is highly variable and can last for years. This is the most appropriate action because it acknowledges the client's feelings of depression and grief as valid and normal following the death of a loved one. By explaining the variability in the duration of grief, the nurse provides reassurance and validation to the client's experience. This approach helps in normalizing the client's emotions and promotes a sense of understanding and acceptance.
Choice A is incorrect because recommending solitary activities may worsen the client's depression by isolating them.
Choice C is incorrect as encouraging avoidance of discussing the death can hinder the client's grieving process.
Choice D is incorrect as cautioning against feeling angry can invalidate the client's emotions.