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: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. The nurse should first address the client's heart rate as an essential vital sign to assess the client's overall physiological status and potential cardiac complications related to anorexia nervosa.
2. Following that, monitoring the client's skin turgor is crucial as it indicates hydration status and can help assess the severity of malnutrition and dehydration.
3. Lanugo (fine hair growth) is a potential condition seen in clients with anorexia nervosa due to malnutrition and low body fat.
4. Monitoring heart rate continuously is important as it can indicate cardiac complications and the impact of malnutrition.
5. Hair loss is another parameter to monitor as it can be a sign of malnutrition and can provide insights into the client's nutritional status.
Summary:
Addressing heart rate and skin turgor first is crucial for assessing overall health status and hydration levels. Lanugo is
Extract:
Question 2 of 5
For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?
Correct Answer: D
Rationale: The correct answer is D because a nurse is mandated to report any suspicion of child abuse or neglect, such as the partner tying the child to a bed. This falls under the category of child maltreatment, which must be reported to the appropriate agency to ensure the safety and well-being of the child.
Choices A, B, and C do not involve immediate harm to a vulnerable individual and do not fall under the mandated reporting requirements for nurses.
Question 3 of 5
A nurse is caring for a client with depression. Which intervention should be prioritized? (Hypothetical based on context)
Correct Answer: A
Rationale: The correct answer is A: Monitor for suicidal ideation. This is the priority intervention because individuals with depression are at increased risk for suicide. Monitoring for suicidal ideation allows for early detection and intervention. Encouraging social isolation (
B) is incorrect as social support is crucial in managing depression. Increasing sedative medication (
C) may lead to dependence and does not address the underlying issues. Teaching relaxation techniques (
D) is helpful but not the priority when dealing with potential suicidal risk.
Question 4 of 5
A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Initiates social interactions with caregivers. For individuals with autism spectrum disorder, social skills development is a key goal. By initiating social interactions with caregivers, the adolescent can practice communication, build relationships, and enhance social functioning. This outcome focuses on improving social interaction abilities, which is crucial for the adolescent's overall well-being and integration into society.
Other choices are incorrect because:
B: Acknowledging delusions is not typically a characteristic of autism spectrum disorder.
C: Changing behavior due to peer pressure may not be appropriate or beneficial for someone with autism spectrum disorder.
D: Meeting own needs without manipulating others is a positive trait, but it is not specific to the goals of social interaction and communication targeted in this case.
Question 5 of 5
A nurse is caring for a client who has bulimia nervosa. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's bathroom trips. This is crucial in managing bulimia nervosa as it helps assess potential purging behavior, which is common in individuals with this disorder. Monitoring bathroom trips allows the nurse to intervene promptly if the client engages in harmful behaviors like self-induced vomiting.
Choice B is incorrect because allowing the family to bring food may enable the client's disordered eating patterns.
Choice C is incorrect as clients with bulimia nervosa often struggle with creating healthy meal schedules, so guidance from healthcare professionals is essential.
Choice D is incorrect because excessive exercise can contribute to the maintenance of the disorder.