ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Physical Examination
• Height: 152.4 cm (60 in)
• Weight: 36.7 kg (81 lb)
• BMI: 15.8
• Lanugo
• Decreased skin turgor
• Cold extremities
• Russell’s sign
• Hair loss
• Erosion of teeth enamel
• Client report of constipation
Vital Signs
• Heart rate: 44/min
• Respiratory rate: 20/min
• BP: 86/50 mm Hg
• Temperature: 36.2° C (97.2° F)
Medical History
The client is 18 years old and is being admitted into the inpatient eating disorder clinic. The client has had a history of anorexia nervosa since age 16. BMI has fluctuated from 15 to 19 over the past 3 years. The client reports restricting caloric intake to 400 cal/day, fasting, and dieting. The client also reports frequent episodes of binge eating, self-induced vomiting, frequent laxative use, and exercising three times per day, every day. The client states, “I am so fat. No matter what I do, I can’t get skinny or lose enough weight.” The client’s guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
Question 1 of 5
A nurse is initiating the plan of care for a client who has anorexia nervosa.Exhibits:Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___.
Correct Answer: A,B
Rationale: Bradycardia (44/min) is life-threatening in anorexia due to malnutrition, requiring immediate attention, followed by dehydration (skin turgor) to stabilize.
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 2 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: The client’s history of heavy alcohol use increases withdrawal risk when intake stops, evidenced by prior consumption patterns.
Extract:
Question 3 of 5
A nurse is teaching a client who is about to start taking fluoxetine. The nurse should instruct the client that which of the following supplements interacts adversely with fluoxetine?
Correct Answer: A
Rationale: St. John's wort is known to interact adversely with fluoxetine. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression. St. John's wort also affects serotonin levels, and when combined with fluoxetine, it increases the risk of serotonin syndrome, a potentially life-threatening condition characterized by symptoms like confusion, rapid heart rate, and muscle rigidity. Soy protein, echinacea, and ginkgo biloba do not have significant interactions with fluoxetine that pose such risks.
Question 4 of 5
A nurse is caring for a group of clients in a mental health facility. Which of the following is a task that can be delegated to assistive personnel?
Correct Answer: B
Rationale: Sitting with a client during mealtimes doesn’t require clinical judgment and can be delegated to assistive personnel, who can provide support and monitor intake. Teaching coping mechanisms, discussing relapse, and administering medication require nursing expertise and cannot be delegated.
Question 5 of 5
A nurse in an acute care facility is planning care for a client with a history of alcohol use disorder who is admitted while intoxicated. Which of the following interventions should the nurse implement?
Correct Answer: A
Rationale: Implementing seizure precautions is critical for a client with alcohol use disorder admitted while intoxicated. Alcohol withdrawal can lead to seizures, a life-threatening risk, requiring a safe environment and emergency readiness. Orthostatic hypotension monitoring is useful but secondary; methadone is for opioid withdrawal, not alcohol; and acidifying urine is irrelevant to alcohol management.