ATI RN
ATI RN Mental health 2019 NGN II Questions
Extract:
Question 1 of 5
A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?
Correct Answer: B
Rationale:
Correct
Answer: B. Having the provider assess the client within 1 hr after applying the restraints is the most appropriate action. This is crucial to ensure the client's safety, assess the need for continued restraint, and address any potential physical or emotional harm caused by the restraints. This prompt assessment can guide further care planning and interventions.
Incorrect
Choices:
A: Requesting prescription renewal every 8 hr is unnecessary and may not address the immediate need for assessment.
C: Hourly evaluation is important, but having the provider assess the client promptly is more critical for timely intervention.
D: Obtaining a prescription on an as-needed basis may delay necessary assessment and intervention, risking the client's safety.
Question 2 of 5
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
Correct Answer: C
Rationale: The correct answer is C: The client's manifestations developed suddenly. Delirium is characterized by an acute onset of confusion, disorientation, and altered consciousness. The sudden development of symptoms differentiates delirium from other conditions like dementia.
Choices A and B do not specifically indicate delirium and could be seen in various mental health disorders.
Choice D suggests potential cognitive impairment, which could be present in delirium but is not a specific indicator.
Choices E, F, and G are irrelevant. In summary, the sudden onset of symptoms is a key feature that differentiates delirium from other conditions in this scenario.
Question 3 of 5
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Document the client's refusal of the treatment in the medical record. This is the appropriate action because it respects the client's autonomy and ensures that the refusal is properly documented for legal and ethical reasons. It also allows for further discussions with the client in the future.
Choice A is incorrect because the client's involuntary commitment does not negate their right to refuse treatment.
Choice C is incorrect as ECT does require informed consent.
Choice D is inappropriate as involving the client's family without the client's consent violates the client's privacy and autonomy.
Question 4 of 5
A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A: Blood pH 7.60. A pH of 7.60 indicates alkalosis, which can lead to serious complications like cardiac arrhythmias. The nurse should intervene immediately by informing the healthcare provider and implementing measures to correct the pH imbalance.
B: BUN 21 mg/dL is within the normal range and does not require immediate intervention.
C: +2 edema of the lower extremities is a common finding in clients with anorexia nervosa but does not warrant immediate intervention unless it is severe or worsening.
D: Lanugo covering the body is a common symptom in clients with anorexia nervosa and does not require immediate intervention.
In summary, the other choices are not as critical as a significantly elevated blood pH level, which can lead to life-threatening complications.
Question 5 of 5
A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Lanugo is fine hair growth due to malnutrition. Bradycardia is common in anorexia nervosa due to slowed metabolism. Russell's sign, calluses on knuckles from induced vomiting, is a characteristic finding. Diarrhea (
C) is not typically associated with anorexia nervosa. Hypotension (
D) is not a common finding; instead, orthostatic hypotension may occur.
Choices F and G are not provided.