ATI RN
ATI RN Mental Health 2023 Exam 3 Questions
Extract:
Question 1 of 5
For which of the following clients is a nurse considered a mandated reporter to the appropriate agency?
Correct Answer: D
Rationale: The correct answer is D because a nurse is mandated to report any suspicion of child abuse or neglect, such as the partner tying the child to a bed. This falls under the category of child maltreatment, which must be reported to the appropriate agency to ensure the safety and well-being of the child.
Choices A, B, and C do not involve immediate harm to a vulnerable individual and do not fall under the mandated reporting requirements for nurses.
Extract:
Physical Examination
• Height: 152.4 cm (60 in)
• Weight: 36.7 kg (81 lb)
• BMI: 15.8
• Lanugo
• Decreased skin turgor
• Cold extremities
• Russell’s sign
• Hair loss
• Erosion of teeth enamel
• Client report of constipation
Vital Signs
• Heart rate: 44/min
• Respiratory rate: 20/min
• BP: 86/50 mm Hg
• Temperature: 36.2° C (97.2° F)
Medical History
The client is 18 years old and is being admitted into the inpatient eating disorder clinic. The client has had a history of anorexia nervosa since age 16. BMI has fluctuated from 15 to 19 over the past 3 years. The client reports restricting caloric intake to 400 cal/day, fasting, and dieting. The client also reports frequent episodes of binge eating, self-induced vomiting, frequent laxative use, and exercising three times per day, every day. The client states, “I am so fat. No matter what I do, I can’t get skinny or lose enough weight.” The client’s guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
Question 2 of 5
A nurse is initiating the plan of care for a client who has anorexia nervosa.Exhibits:Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___.
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. The nurse should first address the client's heart rate as an essential vital sign to assess the client's overall physiological status and potential cardiac complications related to anorexia nervosa.
2. Following that, monitoring the client's skin turgor is crucial as it indicates hydration status and can help assess the severity of malnutrition and dehydration.
3. Lanugo (fine hair growth) is a potential condition seen in clients with anorexia nervosa due to malnutrition and low body fat.
4. Monitoring heart rate continuously is important as it can indicate cardiac complications and the impact of malnutrition.
5. Hair loss is another parameter to monitor as it can be a sign of malnutrition and can provide insights into the client's nutritional status.
Summary:
Addressing heart rate and skin turgor first is crucial for assessing overall health status and hydration levels. Lanugo is
Extract:
Question 3 of 5
A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C because the client stating they are unable to eat more than once a day indicates potential malnutrition and a risk to their physical health. This finding requires immediate attention as malnutrition can lead to serious complications.
Choice A relates to grief and anger, which are important but not an immediate priority.
Choice B focuses on guilt, which is also significant but does not pose an immediate threat to physical health.
Choice D is about recalling negative experiences, which may indicate emotional distress but does not present an immediate physical risk.
Question 4 of 5
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,E
Rationale: The correct instructions are B, C, and E. Installing sensor devices on outside doors helps prevent wandering. Positioning the mattress on the floor reduces fall risk. Putting locks at the top of doors prevents the client from wandering. Placing the client in a reclining chair does not address the wandering issue. Encouraging physical activity prior to bedtime may increase agitation and worsen wandering.
Question 5 of 5
A nurse is assessing a client during a follow-up at a health clinic. The client reports that they struggle to take antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?
Correct Answer: C
Rationale: The correct answer is C: Ask the client if the medication is causing adverse effects. This is the most appropriate action to improve medication adherence because it addresses a potential barrier to taking the medication regularly. By inquiring about adverse effects, the nurse can assess if the client is experiencing any side effects that may be impacting their ability or willingness to take the medication. By identifying and addressing these issues, the nurse can work with the client to find solutions or alternatives to improve adherence.
Other choices are incorrect:
A: Threatening admission to an inpatient care facility is coercive and not a respectful or effective approach to improving adherence.
B: Discussing provider goals may not directly address the client's challenges with medication adherence.
D: Requesting a second medication without addressing the underlying issues may not solve the problem and can lead to further complications.