ATI RN
ATI RN Mental Health 2023 Exam 2 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 crucial to ensure the child's safety while in restraints. Monitoring vital signs every 15 minutes allows the nurse to promptly identify any signs of distress or complications related to the restraints, such as changes in blood pressure, heart rate, or respiratory rate. This frequent monitoring ensures early intervention if necessary, promoting the child's well-being.
Choice A (Keep the restraints on for a minimum of 1 hour) is incorrect because there is no specific time frame mentioned in best practice guidelines for keeping restraints on, and it is essential to assess the need for restraints continuously.
Choice C (Ask the provider to renew the prescription for the restraints every 24 hours) is incorrect as it focuses on administrative tasks rather than immediate patient safety monitoring.
Choice D (Arrange an in-person evaluation by the child's provider within 2 hours of initiating restraints) is incorrect as it does not address
Question 2 of 5
A nurse is caring for a client who states, 'I am too embarrassed to tell anyone what I did last night.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: Let's discuss what you feel embarrassed about. This response demonstrates active listening and empathy, encouraging the client to open up about their feelings without judgment. It shows support and willingness to help address the underlying issue.
Choice B is incorrect as it may pressure the client to disclose information prematurely.
Choice C is dismissive and does not validate the client's feelings.
Choice D generalizes and does not address the client's specific situation.
Question 3 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: B
Rationale: The correct answer is B: Focus the client on reality-based activities. This is because redirecting the client's focus to reality-based activities can help ground them and reduce the intensity of the hallucinations. Avoiding direct questions (
A) may not address the client's current distress. Conveying sympathy (
C) is important but may not directly address the hallucinations. Telling the client her experience is not real (
D) may invalidate their feelings and worsen the situation. It is crucial to engage the client in reality-based activities to help them cope effectively.
Question 4 of 5
A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?
Correct Answer: C
Rationale: The correct answer is C: Varenicline. This is because Varenicline is a medication specifically indicated for smoking cessation. It works by reducing the pleasurable effects of nicotine and decreasing cravings. Naltrexone (
A) is used for alcohol and opioid dependence, not smoking cessation. Donepezil (
B) is used to treat Alzheimer's disease. Disulfiram (
D) is used to deter alcohol consumption by causing unpleasant effects when alcohol is ingested. Hence, the nurse should expect the provider to prescribe Varenicline to help the client quit smoking effectively.
Extract:
Provider’s Note
0230:
Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
Vital Signs
0200:
Temperature 38.6° C (101.5° F)
Heart rate 104/min
Respiratory rate 18/min
Blood pressure 158/96 mm Hg
Oxygen saturation 98% on room air
Nurses’ Notes
0205:
Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police, but not able to identify place or time. Family notified.
Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular.
During assessment, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair.
0230:
Client’s adult child arrived to the ED and went to client’s room. Client identified family member. Client is pacing and agitated, and states, “I don’t understand why I am here.” Adult child asks nurse to talk outside of room and states, “I don’t know why they are so confused. They are not normally like this.” Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, client voided 250 mL of dark yellow, cloudy urine.
Laboratory Results
0230:
Serum toxicology screen:
Alcohol 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Question 5 of 5
The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.Exhibits:For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
| Options | Delirium | Alzheimer’s Disease |
|---|---|---|
| Sudden onset of confusion | ||
| Hallucinations | ||
| Agitation | ||
| Current medical diagnosis |
Correct Answer:
Rationale:
Correct Answer:
Rationale:
- Sudden onset of confusion is more indicative of delirium due to its acute and fluctuating nature.
- Hallucinations can be seen in both delirium and Alzheimer's but are more common in delirium.
- Agitation is a common symptom in delirium and can also occur in Alzheimer's.
- Current medical diagnosis should also be checked to understand the overall clinical picture.
-
Therefore, the correct answer selects all options as each finding can potentially support either delirium or Alzheimer's disease.