ATI LPN
ATI PN Mental Health 2023 Questions
Extract:
Nurse's Notes: 0205:
Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified.
Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular.
During data collection, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair.
0230:
Client’s adult child arrived to the ED and went to client’s room. Client identified family member. Client is pacing and agitated, and states, "I don’t understand why I am here.” Adult child asks nurse to talk outside of room and states, “I don’t know why they are so confused. They are not normally like this.” Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
0415:
Client admitted to medical-surgical unit.
Peripheral IV initiated in right arm by RN. Client is agitated, trying to pull out IV, and yelling, “I am leaving now!”
1400:
Client is awake, oriented to person and place, but drowsy. Adult child at bedside. Client is watching television. No hallucinations observed since admission to unit. IV fluids infusing to right arm. Providers Notes: 0230:
Client diagnosis: delirium secondary to a urinary tract infection and dehydration.
0400:
Will transfer client to medical-surgical unit.
Medication Administration Record: 0415:
0.9% sodium chloride IV at 125 mL/hr
Lorazepam 1 mg IV
Sulfamethoxazole/trimethoprim 800/160 mg tab PO
Acetaminophen 325 mg 2 tabs PO
0900:
Lorazepam 1 mg IV
Laboratory Results:
0230:
Serum toxicology screen:
Alcohol: 60 mg/dL (80 to 200 mg intoxication)
Vital Signs:0200:
Temperature 38.6°C (101.5°F)
Heart rate 104/min
Respiratory rate 18/min
Blood pressure 158/96 mm Hg
Oxygen saturation 98% on room air
0415:
Temperature 38.6°C (101.5°F)
Heart rate 108/min
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 98% on room air
1400:
Temperature 37.2°C (98.9°F)
Heart rate 78/min
Respiratory rate 16/min
Blood pressure 128/84 mm Hg
Question 1 of 5
The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply)
Correct Answer: A,B,D,E,F
Rationale: Decreased temperature (
A), no hallucinations (
B), lower heart rate (
D), improved orientation (E), and normalized BP (F) show improvement. Stable oxygen (
C) doesn’t change.
Extract:
Question 2 of 5
A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: This open-ended response encourages sharing and support. A assumes, B blames, and C minimizes the client’s experience.
Question 3 of 5
A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?
Correct Answer: A,B,D
Rationale: Hypomagnesemia (
A), muscle wasting (
B), and hypokalemia (
D) stem from purging in bulimia. Lanugo (
C) is specific to anorexia’s extreme weight loss.
Question 4 of 5
A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?
Correct Answer: C
Rationale: Using 'I' statements fosters a non-threatening environment, reducing defensiveness and enhancing learning. Longer sessions (
A) may fatigue older adults, long-term goals (
B) don’t directly address barriers, and bedtime timing (
D) reduces concentration.
Question 5 of 5
A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?
Correct Answer: B
Rationale: Cardiac arrhythmia increases ECT risks due to seizure-induced heart stress. Renal colic (
A), asthma (
C), and Crohn’s (
D) require management but aren’t direct contraindications.