ATI RN
ATI Mental Health Exam II Questions
Extract:
Question 1 of 5
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because psychotic thinking can pose a significant risk to the client's safety and well-being. Psychotic symptoms may include hallucinations or delusions, which can impair the client's ability to make rational decisions or accurately perceive reality. Assessing for psychotic thinking allows the nurse to determine the client's current mental status and the need for immediate interventions to ensure safety. Asking the client to identify the cause of the crisis (
B), identifying coping skills (
C), and support systems (
D) are important assessments but not as critical as assessing for psychotic thinking in this situation.
Question 2 of 5
A nurse caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous infusion at 1,200 U/hr. Available is heparin 25,000 units in 500 mL DSW. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 24
Rationale:
Rationale:
To determine the mL/hr rate, calculate the total units of heparin in 1 hr (1,200 U) and then set up a proportion using the volume of heparin solution. Given 25,000 U in 500 mL, 1,200 U will be in x mL. Cross multiply to find x = 24 mL/hr. This is the correct answer as it ensures the prescribed dose of heparin is administered accurately. Other choices are incorrect as they do not align with the calculations based on the prescribed infusion rate and concentration of heparin solution.
Question 3 of 5
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
Correct Answer: B
Rationale: The correct answer is B: Decrease anxiety to a tolerable level. In this scenario, the client with OCD is engaging in the compulsive behavior of constantly picking up after others as a way to alleviate their anxiety. People with OCD often engage in repetitive behaviors to reduce distress caused by obsessions. This behavior provides temporary relief from anxiety, making it tolerable for the individual.
Choices A, C, and D are incorrect because the primary motivation behind the client's behavior is not to focus attention on meaningful tasks, manipulate or control others, or limit interaction time, but rather to manage anxiety.
Question 4 of 5
A nurse assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. In anorexia nervosa, severe weight loss leads to a decrease in heart rate to conserve energy. This is a compensatory mechanism to maintain perfusion to vital organs. Dental erosion (
A) is more commonly associated with bulimia nervosa due to frequent vomiting. Hyperactive bowel sounds (
B) are not typically seen in anorexia nervosa as the gastrointestinal system slows down due to malnutrition. Hypertension (
C) is not a common finding in anorexia nervosa as decreased caloric intake usually leads to low blood pressure.
Therefore, the correct answer is D due to the physiological response to severe weight loss in anorexia nervosa.
Question 5 of 5
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
Correct Answer: D
Rationale: The correct answer is D: Preparing for artificial ventilation. Severe serotonin syndrome can lead to respiratory failure due to hyperthermia, muscle rigidity, and altered mental status. Artificial ventilation is crucial to maintain adequate oxygenation and prevent respiratory arrest. Padding side rails (choice
A) may prevent injury, but ensuring respiratory function takes precedence. Applying a cooling blanket (choice
B) may help reduce hyperthermia but does not address the immediate threat of respiratory compromise. Administering an anticonvulsant (choice
C) may be beneficial for seizures in serotonin syndrome but does not address the primary concern of respiratory distress.