ATI RN
ATI RN Mental Health 2023 Exam 2 Questions
Extract:
Provider’s Note
0230:
Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
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
Nurses’ 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 assessment, 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 their room, client voided 250 mL of dark yellow, cloudy urine.
Laboratory Results
0230:
Serum toxicology screen:
Alcohol 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Question 1 of 5
The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.Exhibits:For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
| Options | Delirium | Alzheimer’s Disease |
|---|---|---|
| Sudden onset of confusion | ||
| Hallucinations | ||
| Agitation | ||
| Current medical diagnosis |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Sudden onset of confusion is more indicative of delirium due to its acute and fluctuating nature.
- Hallucinations can be seen in both delirium and Alzheimer's but are more common in delirium.
- Agitation is a common symptom in delirium and can also occur in Alzheimer's.
- Current medical diagnosis should also be checked to understand the overall clinical picture.
-
Therefore, the correct answer selects all options as each finding can potentially support either delirium or Alzheimer's disease.
Extract:
Vital Signs
0200:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 104/min
o Respiratory rate: 18/min
o Blood pressure: 158/96 mm Hg
o Oxygen saturation: 98% on room air
0415:
•
o Temperature: 38.6° C (101.5° F)
o Heart rate: 108/min
o Respiratory rate: 20/min
o Blood pressure: 148/94 mm Hg
o Oxygen saturation: 98% on room air
Nurses’ Notes
0205:
The client was brought to the ED by police after being found wandering on the street. The client was able to provide their identity to the police, but was not able to identify the place or time. The family was notified. The client appeared confused and agitated. Their appearance was disheveled. Their mucous membranes were dry. Their lungs were clear and equal, and their heart rhythm was regular. During the assessment, the client stated, “Can you ask that person to leave my room?” The client was pointing to an empty chair.
0230:
The client’s adult child arrived at the ED and went to the client’s room. The client identified the family member. The client was pacing and agitated, and stated, “I don’t understand why I am here.” The adult child asked the nurse to talk outside of the room and stated, “I don’t know why they are so confused. They are not normally like this.” The adult child stated that the client has a past medical history of hypertension and alcohol-related cirrhosis. Upon returning to their room, the client voided 250 mL of dark yellow, cloudy urine.
0415:
The client was admitted to the medical-surgical unit. A peripheral IV was initiated in the right arm. The client was agitated, trying to pull out the IV, and yelling, “I am leaving now!”
Provider’s Note
0230: Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
0400: The client will be transferred to the medical-surgical unit.
Laboratory Results
0230: Serum toxicology screen: Alcohol 60 mg/dL (80 to 200 mg/dL indicates mild to moderate intoxication)
Question 2 of 5
The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.Exhibits:Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.
Correct Answer: B,D,E
Rationale: The correct answer is B, D, and E. Reorienting the client helps maintain their cognitive function. Approaching slowly minimizes agitation and builds trust. Maintaining a low-stimulation environment supports the client's well-being. A is incorrect as family support can be beneficial. C is unnecessary unless there are specific reasons.
Extract:
Vital Signs
Blood pressure: 112/68 mm Hg
Temperature: 37° C (98.6° F)
Heart rate: 64/min
Respiratory rate: 12/min
Oxygen saturation: 98% on room air
Medical History
A 19-year-old female client presents to the clinic accompanied by her parents. The parents indicate they "have to do something or she is going to end up in jail - we cannot believe a thing she tells us.” The client is disinterested, standing with arms crossed, and not answering questions when addressed. Her parents indicate she “can be very nice to be around, but when denied something she wants, she becomes aggressive and abusive.” Parents report impulsivity and that the client does not show remorse for her actions. According to her parents, “she is reckless and irresponsible.” The parents indicate this type of behavior started around age 13 and has recently become more frequent. The client states, “I can do what I want. Nobody is going to tell me what to do.”
Question 3 of 5
A nurse is caring for a client. Exhibits:Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Correct Answer: B, A&E, C&E
Rationale: The correct answer is B, A&E, C&E. The client is most likely experiencing a personality disorder, which falls under the category of mental health conditions. The nurse should address this by first assessing the specific personality disorder the client may have (choice
A) to tailor the care plan accordingly. Next, the nurse should maintain a low-stimuli environment and establish clear boundaries (choices
A) to help manage the client's behaviors and promote a sense of safety. The nurse should monitor daily weight and proactive behavior (choice
C) to assess physical and psychological well-being, and monitor aggressive and violent behavior and deceitfulness (choice E) to evaluate progress and potential risks. The other choices are incorrect as they do not address the specific mental health condition or appropriate actions and parameters for managing and assessing the client's condition effectively.
Extract:
Question 4 of 5
A nurse is caring for a client who states, 'I am too embarrassed to tell anyone what I did last night.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: Let's discuss what you feel embarrassed about. This response demonstrates active listening and empathy, encouraging the client to open up about their feelings without judgment. It shows support and willingness to help address the underlying issue.
Choice B is incorrect as it may pressure the client to disclose information prematurely.
Choice C is dismissive and does not validate the client's feelings.
Choice D generalizes and does not address the client's specific situation.
Question 5 of 5
A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?
Correct Answer: A
Rationale: The correct answer is A: Geriatric Depression Scale. This screening tool is essential for assessing depression in older adults, as it helps identify symptoms that may be overlooked. Depression is common in the elderly and can have significant impacts on their overall health and well-being. The Geriatric Depression Scale is specifically designed to assess depression in older adults, making it a crucial test for the nurse to include in their screening assessments.
The other choices are incorrect because:
B: Pain Assessment in Advanced Dementia Scale - This tool is not relevant for screening active older adult clients for general health assessments.
C: CAGE Questionnaire - This tool is used for assessing alcohol abuse, which may not be the primary focus of screening for active older adults.
D: Denver II Developmental Screening Test - This test is designed for children, not older adults, and is not suitable for screening in this population.