ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C. Reporting eating twice in the past week is a critical finding to report because it indicates a significant decrease in nutritional intake, which can lead to serious health complications. This is particularly concerning in the context of mania, as individuals experiencing manic episodes may neglect self-care, including eating regularly. In contrast, choices A, B, and D are all common behaviors associated with mania but do not pose an immediate threat to the client's physical health.
Choice A may indicate a hygiene issue, choice B is a symptom of pressured speech often seen in mania, and choice D reflects disinhibition commonly observed in manic states. However, these behaviors do not directly jeopardize the client's well-being in the same way as severe nutritional deprivation.
Question 2 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale:
Correct Answer: B, C, E
Rationale:
B: Installing sensor devices on outside doors will alert the caregiver if the client tries to wander at night, preventing falls and ensuring safety.
C: Positioning the mattress on the floor reduces the risk of injury if the client falls out of bed during the night.
E: Putting locks at the top of doors can prevent the client from wandering outside at night, reducing the risk of falls and injuries.
Incorrect
Choices:
A: Placing the client in a reclining chair may not address the wandering issue and could lead to discomfort or pressure ulcers.
D: Encouraging physical activity prior to bedtime may increase restlessness and agitation, potentially worsening the wandering behavior.
Other options are not provided, but it's important for the caregiver to maintain a safe environment and provide appropriate supervision for the client.
Question 3 of 5
A nurse is caring for a client who is scheduled for electroconvulsive treatment (ECT). The client states, 'I no longer want to have the treatment.' Which of the following statements would be an appropriate response from the nurse?
Correct Answer: C
Rationale:
Correct Answer: C
Rationale:
1. Respect for autonomy: Clients have the right to make decisions about their own treatment.
2. Advocacy: The nurse should communicate the client's decision to the provider.
3. Ethical principle: Upholding the client's right to refuse treatment is crucial in maintaining trust and promoting autonomy.
Summary:
A: Incorrect. Involuntary admission does not negate the client's right to refuse treatment.
B: Incorrect. Focusing on potential benefits disregards the client's autonomy.
D: Incorrect. Administering medication without addressing the client's refusal is unethical.
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 4 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:
Question 5 of 5
A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, 'I can't think about that until after my first grandchild is born next week.' The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?
Correct Answer: A
Rationale: The correct answer is A: Suppression. Suppression involves consciously choosing to postpone dealing with thoughts, feelings, or impulses. In this scenario, the client is avoiding thoughts of their diagnosis by focusing on a future event. Compensation involves overemphasizing a trait to offset a perceived weakness. Regression involves reverting to an earlier stage of development. Sublimation involves channeling unacceptable impulses into constructive activities. In this case, the client's behavior aligns most closely with suppression, as they are consciously delaying thoughts about their diagnosis.