ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Maintain a low level of environmental stimuli. Command hallucinations in schizophrenia can be exacerbated by high levels of environmental stimuli. By minimizing distractions and maintaining a calm environment, the nurse can help reduce the likelihood of the client experiencing these hallucinations. This intervention supports the client's ability to focus and differentiate between reality and hallucinations.
Choice B: Avoid making eye contact when speaking with the client is incorrect because avoiding eye contact may isolate the client further and hinder therapeutic communication.
Choice C: Encourage increased socialization during group therapy is incorrect because group therapy may overwhelm the client and increase the risk of experiencing command hallucinations.
Choice D: Provide reassurance and comfort for the client through touch is incorrect because touch may not be appropriate for all clients and may not directly address the underlying issue of command hallucinations.
Question 2 of 5
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Failure to recognize familiar objects. In Alzheimer's disease, individuals experience cognitive decline, including memory loss and difficulty recognizing familiar objects or people. This is due to brain changes affecting memory and perception. Excessive motor activity (
A) is not typically a hallmark of Alzheimer's; rather, individuals may have decreased motor skills. Rapid mood swings (
C) are more commonly seen in mood disorders, not specific to Alzheimer's. Altered level of consciousness (
D) is not a primary feature of Alzheimer's; individuals may have periods of confusion but usually remain conscious.
Question 3 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: C
Rationale: The correct answer is C: Blood glucose 256 mg/dL (74 to 106 mg/dL). Elevated blood glucose levels can be a side effect of risperidone, an atypical antipsychotic medication. Notify the provider to assess for potential hyperglycemia, which can lead to serious complications like diabetic ketoacidosis.
A, B, and D are within normal ranges. A slightly low or high sodium level, WBC count, or platelet count are not typically concerning in this case.
Question 4 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 5 of 5
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B
Rationale:
Correct Answer: A, B
Rationale:
A: Identifying the client's stressors is important to understand the underlying cause of the behavior and helps in addressing the root issue.
B: Talking to the client using short, simple sentences can help in de-escalating the situation and ensuring effective communication.
C: Speaking to the client in a loud voice may escalate the situation further by increasing agitation and aggression.
D: Requesting security guards to restrain the client should be a last resort and may lead to physical harm and trauma.
E: Standing directly in front of the client can be perceived as confrontational and may escalate the situation further.