ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?
Correct Answer: C
Rationale: Preventing self-harm is the priority due to BPD’s high risk. Support groups, assertiveness, and awareness are secondary.
Question 2 of 5
A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?
Correct Answer: C
Rationale: Environmental cues (clocks, calendars) reduce confusion in delirium. Decision-making is impaired, family visits help, restraints increase agitation.
Extract:
Vital Signs
0200:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 104/min
o Respiratory rate: 18/min
o Blood pressure: 158/96 mm Hg
o Oxygen saturation: 98% on room air
0415:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 108/min
o Respiratory rate: 20/min
o Blood pressure: 148/94 mm Hg
o Oxygen saturation: 98% on room air
Nurses’ Notes
0205:
The client was brought to the ED by police after being found wandering on the street. The client was able to provide their identity to the police, but was not able to identify the place or time. The family was notified. The client appeared confused and agitated. Their appearance was disheveled. Their mucous membranes were dry. Their lungs were clear and equal, and their heart rhythm was regular. During the assessment, the client stated, “Can you ask that person to leave my room?” The client was pointing to an empty chair.
0230:
The client’s adult child arrived at the ED and went to the client’s room. The client identified the family member. The client was pacing and agitated, and stated, “I don’t understand why I am here.” The adult child asked the nurse to talk outside of the room and stated, “I don’t know why they are so confused. They are not normally like this.” The adult child stated that the client has a past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, the client voided 250 mL of dark yellow, cloudy urine.
0415:
The client was admitted to the medical-surgical unit. A peripheral IV was initiated in the right arm. The client was agitated, trying to pull out the IV, and yelling, “I am leaving now!”
Provider’s Note
0230: Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
0400: The client will be transferred to the medical-surgical unit.
Laboratory Results
0230: Serum toxicology screen: Alcohol 60 mg/dL (80 to 200 mg/dL indicates mild to moderate intoxication)
Question 3 of 5
The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.Exhibits:Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.
Correct Answer: B,D,E
Rationale: Reorientation (
B), slow approach (
D), and low stimuli (E) aid delirium management. Limiting family and rotating staff may increase confusion.
Extract:
Question 4 of 5
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client's spiritual needs?
Correct Answer: A
Rationale: Contacting a spiritual advisor supports spiritual needs. Changing subjects dismisses anger, isolation may worsen despair, internalizing hinders grief processing.
Extract:
Provider Prescriptions
• Olanzapine 10 mg tablet PO daily
• Alprazolam 1 mg tablet PO three times daily PRN anxiety
Nurses’ Notes
Client reports hearing voices that are talking about race cars and race tracks. Client appears diaphoretic and pale. Client reports weight gain of 2.2 kg (4.9 lb) in the past week.
Graphic Record
• BP 128/82 mmHg
• Pulse rate 98/min
• Respiratory rate 20/min
• Temperature 39.4° C (103° F)
• SaO2 95%
Question 5 of 5
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Correct Answer: A
Rationale: Temperature of 39.4°C (103°F) suggests fever or NMS, needing urgent attention. BP is normal, weight gain is common, hallucinations expected.