RN ATI Comprehensive Assessment Exam Retake 2023 V2 -Nurselytic

Questions 58

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RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions

Extract:

Nurses: Notes

0700

Client is admitted to the unit. They deny suicidal ideations at this time. Client states, 'I am an assistant to a powerful spirit.' Client is poorly groomed and has body odor.

0900:

Called to the client's room. Client states, 'I cannot believe you put me in a room with spiders on the wall,' Client requests immediate transfer to another room.

1200:

Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states that they have diagnosed the client with schizophrenia. Client is to be started on medication and milieu therapy.



Laboratory Results

0700:

Urine drug screen: negative (negative)



History and Physical

0700:

Majority of client's history is obtained from client's parent who presents with client today. According to the parent, client has been acting strangely for a few months. Client's symptoms have been progressively worsening



In the last month, the client has been seeing things that are not present and believes that they are in a close relationship with 'a powerful spirit.' Client has not been bathing regularly for the last few weeks.



Client has no significant health history. Client reports that they do not take illicit substances or drink alcohol. Client's grandparent has a history of schizophrenia.



Vital Signs

0730:

Heart rate 68/min

Respiratory rate 18/min

BP 118/81 mm Hg

Temperature 37.2°C (98.9°F)


Question 1 of 5

For each potential action, click to specify if the action is indicated or contraindicated for the client.

Correct Answer: B, C, D indicated; A, E contraindicated

Rationale:
Correct
Answer: B, C, D indicated; A, E contraindicated


Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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