ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
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.
Diagnostic Results
Blood alcohol level (BAC) 310 mg/dL (0 to 50 mg/dL)
Provider Prescriptions
Perform Alcohol Use Disorders Identification Test (AUDIT)
Complete blood count
Basic metabolic profile
Nutrition consultation
Consult counselor for grief therapy
Substance use group therapy
Diazepam 10 mg PO three times a day
Propranolol 40 mg PO twice a day
Metoclopramide 10 mg IM every 6 hr PRN nausea and/or vomiting
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 members estimate the client’s last drink was 2 hours ago.
Vital Signs
Admission, 1600:
•
o Temperature: 36.1°C (97°F)
o Blood pressure: 98/66 mm Hg
o Heart rate: 76/min
o Respiratory rate: 10/min
o Pulse oximetry: 95% on room air
Day 2, 0800:
•
o Temperature: 37.3°C (99.1°F)
o Blood pressure: 198/86 mm Hg
o Heart rate: 116/min
o Respiratory rate: 22/min
Hospital day 5, 0800:
•
o Temperature: 36.1°C (97°F)
o Blood pressure: 128/66 mm Hg
o Heart rate: 74/min
o Respiratory rate: 12/min
o Pulse oximetry: 96% on room air
Question 1 of 5
A nurse is reviewing the day 5 vital signs and nurse’s notes.A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.
Correct Answer: B,C,D,E
Rationale: Group therapy (
B), improved appetite (
C), cognition (
D), and stable vitals (E) show progress in alcohol use disorder treatment. Self-reported alcohol reduction (
A) is unreliable, and grief stages (F) are subjective.
Extract:
Question 2 of 5
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: Eating only twice in a week signals severe nutritional neglect, risking physical complications in mania, requiring urgent reporting. Hygiene neglect, rhyming speech, and sexual comments are notable but less immediately critical.
Extract:
Nurses’ Notes
2000:
Client presents to the triage desk accompanied by a friend. The client states, “I need help. I was raped about an hour ago.” The client’s friend states, “I think they may have been drugged.” Allergies: penicillin, doxycycline Physical exam: General: exhibits anxiety Respiratory: breath sounds clear Cardiovascular: S1, S2, no murmur Abdomen: soft, mildly tender Skin: bruising to upper arms bilaterally, broken fingernails
Vital Signs
2015:
Blood pressure: 128/88 mm Hg
Heart rate: 80/min
Respiratory rate: 16/min
Temperature: 37°C (98.6°F)
Weight: 67.1 kg (147.9 lbs.)
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
Question 3 of 5
A nurse is caring for a client in the emergency department.Drag words from the choices below to fill in each blank in the following sentence. The nurse should identify that the client’s ------------------------ and -------------------- are consistent with sexual assault.
Correct Answer: A,B
Rationale: GHB in diagnostic results and abdominal tenderness with bruising support sexual assault. Other vitals (BP, temp) are normal and less specific.
Extract:
Question 4 of 5
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?
Correct Answer: C
Rationale: A client with bipolar disorder exhibiting poor impulse control presents an immediate safety concern. Poor impulse control can lead to risky behaviors, self-harm, or harm to others, necessitating an urgent update to the care plan with safety measures like close supervision or medication adjustments. Anorexia-related fear of weight gain requires monitoring but not immediate safety updates; tangential speech in schizophrenia is a symptom managed through ongoing care; and memory issues in Alzheimer’s, while distressing, don’t typically pose an immediate safety risk.
Question 5 of 5
A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?
Correct Answer: B
Rationale: During the working phase, the nurse’s primary task is to evaluate progress toward predetermined goals. This phase focuses on active problem-solving and assessing intervention effectiveness, crucial for addressing the client’s issues. Confidentiality and boundaries are set in the orientation phase, while objectives may be adjusted but are primarily established earlier.