ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is preparing to administer haloperidol 7 mg IM to a client who is severely agitated. Available is haloperidol injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1.4
Rationale: Dose (7 mg) ÷ Concentration (5 mg/mL) = 1.4 mL, rounded to the nearest tenth.
Question 2 of 5
A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, 'I think my blackouts are actually caused by low blood sugar.' The nurse should recognize the client is using which of the following defense mechanisms?
Correct Answer: D
Rationale: Rationalization justifies blackouts with a false reason (low blood sugar). Suppression represses, sublimation redirects, projection attributes elsewhere.
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 prescribed massage therapy to treat panic disorder. The client states, 'I can’t stand to be touched by another person.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Advocating for an alternative respects the client’s discomfort. Reassurance dismisses, gloves don’t solve, probing is intrusive.
Question 5 of 5
A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?
Correct Answer: A
Rationale: Acknowledging difficulty validates emotions empathetically. Denying guilt dismisses, personal stories shift focus, counseling is premature.