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.
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.
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Therefore, the correct answer selects all options as each finding can potentially support either delirium or Alzheimer's disease.
Extract:
Question 2 of 5
A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "We are concerned about you and need to keep you safe." This response is appropriate because it acknowledges the client's demand for privacy while also emphasizing the nurse's primary responsibility to ensure the client's safety. It addresses the client's feelings of being cared for and understood, which can help build trust.
Choice A is incorrect because it does not address the client's request for privacy and may come across as dismissive.
Choice B is incorrect as it suggests compliance with the treatment plan as a condition for privacy, which may not be appropriate in this situation.
Choice C is incorrect as safety contracts are not considered effective in preventing suicide and may provide a false sense of security.
Question 3 of 5
A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?
Correct Answer: B
Rationale: The correct answer is B: Chlordiazepoxide. This medication is a benzodiazepine commonly used to manage acute alcohol withdrawal symptoms by reducing anxiety and preventing seizures. It acts by enhancing the inhibitory effects of gamma-aminobutyric acid (GAB
A) in the brain, helping to stabilize the client during withdrawal. Disulfiram (
A) is used to deter alcohol consumption by causing unpleasant effects if alcohol is consumed. Bupropion (
C) is an antidepressant and is not typically used for alcohol withdrawal. Buprenorphine (
D) is a medication used for opioid addiction and is not typically indicated for alcohol withdrawal.
Question 4 of 5
A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B: "I should let my counselor know if I am having trouble sleeping." This statement indicates an understanding of relapse prevention as changes in sleep patterns can be an early sign of relapse in schizophrenia. By communicating this to the counselor, the client can receive appropriate support and interventions.
A: "I should listen carefully to the voices to hear what they're saying." This statement is incorrect as it encourages engaging with auditory hallucinations, which can exacerbate symptoms.
C: "I should avoid being around others if I think I'm having a relapse." This statement is incorrect as social withdrawal can worsen symptoms and isolation is not recommended.
D: "I should avoid watching television when I am hearing voices." This statement is incorrect as it does not address the underlying issue of seeking help from a counselor for symptom management.
Question 5 of 5
A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?
Correct Answer: C
Rationale: The correct answer is C: Blood glucose 256 mg/dL (74 to 106 mg/dL). Elevated blood glucose levels can be a side effect of risperidone, an atypical antipsychotic medication. Notify the provider to assess for potential hyperglycemia, which can lead to serious complications like diabetic ketoacidosis.
A, B, and D are within normal ranges. A slightly low or high sodium level, WBC count, or platelet count are not typically concerning in this case.